Our Heart Failure Case Management Team provides integrated and continuous care for patients hospitalized due to heart failure exacerbation, in accordance with the National Health Insurance Administration’s Heart Failure Post-Acute Care (HF-PAC) program. The team is composed of professionally trained case managers with expertise in cardiovascular care. Working closely with the multidisciplinary team, we aim to support patients through every stage of care—from hospitalization to discharge and home care, enhancing both the quality of care and the quality of life.
1. Continuity of Care Before and After Discharge
We provide individualized patient education before discharge, follow-up calls after discharge, regular heart failure clinic appointments, and a dedicated hotline for patient inquiries.
2. Comprehensive Health Needs Assessment and Comorbidity Management
We assess patients’ overall health needs, coordinate care for comorbidities such as diabetes, hypertension, and renal dysfunction, and deliver integrated, patient-centered care.
3. Support for Treatment Planning and Communication
We assist physicians in explaining treatment plans and care goals, support shared decision-making, and help address patient concerns throughout the care process.
4. Emotional Support and Resource Referral
We offer emotional support to patients and families, and refer to psychological counseling, social work, nutritionist, pharmacist, cardiac rehabilitation, long-term care, palliative care services when needed.
5. Development of Patient Education and Clinical Research
We engage in the development of heart failure education materials, patient-centered teaching strategies, and participate in nursing research to improve care quality and outcomes.
Related Links
Integrated Heart Failure Team(Chinese)
Contact Information
Heart Failure Case Management Team, Nursing Department
Address: No. 7, Zhongshan S. Road, Taipei City
Inquiry mailbox