Target: HF Strategies and Clinical Tools

ACCF/AHA Guidelines for the Management of Heart Failure

These guidelines provide important updates to the Heart Failure Guidelines and the Focused Updates.

Readmission Checklist

There are multiple reasons why a heart failure patient may require readmission shortly after their initial heart failure hospitalization. This document helps your team to identify potential gaps in transitional care that contribute to potentially preventable readmissions. This tool will help you quickly identify potential gaps in hospital, transitional, and post-discharge care for heart failure patients which contribute to potentially preventable readmission.

Discharge Checklist

This is an example of a HF discharge checklist that can be used by hospitals. This is a general algorithm intended to assist in the management of HF patient, and delineates the recommended discharge criteria for these patients. This clinical tool is not intended to replace individual medical judgment or individual patient needs.

Telephone Follow-up Form

This form was designed to help make early follow up on recently discharged heart failure patients easier. Studies have proven that early follow up with patients significantly reduces readmission rates and improves overall quality of life for the patient. This quality improvement tool makes it simple to perform a comprehensive follow up that is comprehensive enough to use on its own or flexible enough to incorporate any addition or deletion of questions as deemed appropriate by the provider.


This document is intended to provide a brief rationale as to each of the measures that are measured under Target: Heart Failure for each of the three key categories:

  • Medication Optimization
  • Early Follow-up Care Coordination
  • Enhanced Patient Education.

LACE+ Calculator(link opens in new window)(link opens in new window)

The LACE index (score 0-19) uses 4 variables to predict the risk of death or urgent readmission within 30 days after hospital discharge: LOS (L), acuity of admission (A), comorbidity (C) and ED visits in previous 6 months (E).

The LACE+ Index (score 0-90) is a modified version of the LACE index in which each patient receives a score based on all the same parameters used by LACE, as well as the following: age; gender; teaching status of the hospital; number of day son alternative level of care during admission; number of elective admissions in previous year; number of urgent admissions in previous year.

Heart Failure Provider Toolkit

The Get With The Guidelines/Target: Heart Failure Enhanced Heart Failure Patient Education Prior to Hospital Discharge fact sheet was developed to explain the importance of patient education and the rationale for why specific information is important to obtain. Patient education is a critical success factor in helping patients manage their heart failure. By ensuring that your hospital has set goals surrounding patient education and has a clear understanding of what information is most important to convey to patients, you can help improve the overall quality of life with those affected by heart failure.

Examples of HF clinical tools

(Submitted by Get With The Guidelines Hospitals)

Discharge Orders/Discharge Instructions

Order Sets

Patient Education