1. Hospital Clinic Hospital RN/MD collaboration Home Home Clinic QC
Collect Data via EHR to identify risk level: labs, weight, current imbalance of symptoms  Treatment/education to improve knowledge of pt. QC
Hospital
Community Environment
Community Environment
Early Education
CDS for Risk Assess for Prevention
Risk Assessment
Hospital
Clinic
Transitional Care
Collect Data via HER to maintain symptoms: labs, weight, symptom management eval trends/patterns for pt. overtime with tools/technology (CDS to alert RN/MD re: high level of risk factors) QC
Quality Care (QC)
Clinic
Collect Data: labs, weight, symptom management
Via tools/ technology (ie. Phone app for med admin. And daily weight record) QC
CDS Supports for best practice
Home
Home
Pt. Safety
Standardized Documentation
RN/MD Collaboration
Non-maleficence
Autonomy
Technologies (smart app)
Pt. w/ Heart failure
Trust
Tools (risk assessment, EHR)
Quality Care
Big Data + Patient Confidentiality= Pt. Outcomes