The transmural care pathway is initiated by the cardiologist, either before discharge from the hospital or from the consultation. This is stated in the medical report, on the nursing discharge letter and on the medication overview for the pharmacy

Medical report: what should it contain?

• The correct diagnosis of heart failure with correct terminology of the type of heart failure (HFrEF , HFmrEF or HFpEF ?).
• The etiology of heart failure and the precipitating factor for decompensation.
• Estimation of the prognosis.
• Any discussed therapy restriction (DNR status).
• Parameters upon discharge (to enable proper follow-up):
  • Blood pressure and heart rate.
  • Weight and target weight.
  • Creatinine (creatinine clearance) and ionogram (sodium, potassium).
• Therapy at discharge with, if possible, a proposal for further titration of the dose of heart failure therapy.
• Inclusion in the heart failure care pathway and whether or not the diary and information booklet were provided.
• Further planning:
  • Next appointment (when and with whom?).
  • Whether or not the patient will follow outpatient cardiac rehabilitation.

Documents upon dismissal

• Medical report for the GP.
• Medication overview for the patient (and any home care nurse) with correct dosage and schedule.
• Medication overview for the pharmacy:
  • On paper stating the diagnosis of heart failure, possibly in a specific envelope addressed to the pharmacy.
  • Or digitally, forwarded from electronic file to MyNexusHealth.
• If not yet available at home:
  • Heart failure diary.
  • Heart failure information booklet.
  • Possible symptoms card.
• Nursing discharge letter stating the following appointments + guidelines for home nursing.
• The next consultation with the cardiologist.
• If necessary: certificates for reimbursement for new medication (if possible directly digitally via CIVARS).
• If necessary and if the patient will not follow outpatient cardiac rehabilitation: referral letter and prescription for at least 9 to 18 sessions of cardiac rehabilitation, muscle strengthening exercises and respiratory physiotherapy with a private physiotherapist near the patient.
• If necessary: referral letter and prescription for home nursing.
• If necessary: follow-up by psychologist/psychiatrist or referral letter from your own psychologist /psychiatrist.

Communication upon dismissal

• Notifying the GP or his/her secretariat (for follow-up planning):
  • Best done by (head) nurse or the heart failure nurse.
  • For specific problems: by the doctor (cardiologist or assistant).
• Notification of home nursing, home care: by social services or (heart failure) nurse (if the patient cannot do this himself).