Follow-up Call Script and Log

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1 Patient Name: Follow-up Call Script and Log The adoption of this worksheet is optional but we have tried to create it so that it will both guide the educator through the follow-up phone calls and help them track the participant s progress while doing so. The worksheets are set up with the following things in mind: 1. Script - The script regarding the calls is laid out to the left side of the page. All the bolded text is meant to be said or asked to the participant. All the unbolded text is process directions. 2. Learning goals - The learning goals are delineated in red. These are the questions that we asked the participant and required that they answer correctly on 2 separate occasions before we feel confident that they have reached that goal. Some of these questions pertain to knowledge of heart failure management and other questions pertain to behaviors they are performing to manage their heart failure. 3. Check off worksheet - As the educator makes each call, they can record along the right side of the page the subjects reply. If the subject correctly replies to a particular question twice, it is then recorded in the last column. When they have done this with all the learning questions, the patient then falls to a maintenance mode of 1 call per month. Introduction (first call only) 1. Let s review your workbook Caring for your Heart Living well with Heart Failure and Daily Water Pill Plan a. When we met, we discussed a lot of information about heart failure b. We will review the material in your workbook as we talk on the phone c. I hope this will help you remember how to care for your heart and to ask any questions about the information we discuss 2. [If patient did not have water pill bottle at initial education session verify that correct pill bottle & lid are marked with stickers.] a. Please get your water pill bottle. b. Can you tell me the name of your water pill? [or what does pill bottle say?] c. Did you mark you bottle with a marker or the sticker? d. [If no] can we do that now? The Health Status/Program Adherence Module script should be reviewed on every call Health Status / Program Adherence Module # QUESTIONS & SUPPLEMENTAL TEXT 3 Have you been to see your doctor or in the hospital since we last [met] spoke? Reply Reply Reply Reply Reply Reply Reply Reply Twice [If yes], Did they change your water pill? 4 Do you have any questions about your heart failure since [we met] our last call? 5 Have you taken your medications today? [If no] why not?

2 # QUESTIONS & SUPPLEMENTAL TEXT Reply Reply Reply Reply Reply Reply Reply Reply Twice [ID and address barriers. Go to the medication section page 3 in workbook to work through the medication issues for rest of call.] 6 Did you weigh yourself today? [or perform your Daily Check-up?] [If yes] Great! Weighing yourself daily is the most important thing you can do to check your water/fluid levels. [If no] why not? [Address barriers: Discuss importance of caring for your heart] Early recognition of changes may keep you feeling well. [If no - Skip to Question #11 then review when & why to check weight and using water pill guide if needed.] 7 How much did you weigh? 8 When did you check your weight? [If wrong time - emphasis timing] You should step on the scale in morning, after urinating, before eating, and before dressing. [Address barriers] 9 Did you write your weight down? [If yes] Great! Let s review your Daily Water Pill Plan together. [If no address barriers] 10 What color weight zone were you in? 11 How many water pills did you take this morning? This afternoon? [If correct] Ok, it seems like you are getting this system down.

3 # QUESTIONS & SUPPLEMENTAL TEXT Reply Reply Reply Reply Reply Reply Reply Reply Twice [If wrong] Ok, how did you decide to take that many pills? What weight zone were you in on your water pill guide? 12 Did you do other parts of your daily check up today? [If they don t know, refer to back of water pill guide to the list. Should assess shortness of breath, dizziness, and edema] 12 a Since our last call has your weight been in the yellow zone? [If yes] How many sequential days? What did you do?

4 Daily Check-up Knowledge Module # QUESTIONS & SUPPLEMENTAL TEXT 13 We are going to refer to the information on the back of your Water Pill Guide. twice () What are three things that you can notice when your heart failure is getting worse? [If correct or incorrect record in column and then review all] You can notice any of the following: a. short of breath b. you have to sleep sitting up to breath well c. you get tired a lot easier d. You can t walk as far without getting short of breath e. You feel faint or dizzy f. swelling in your legs g. your weight is going up (getting heavier) If you notice any of these things, your heart may be having trouble. Great, you seem to know the main signs that heart failure is getting worse. Now let s talk about some of these in a little more detail 14 What place/where can you check on your body to see if it is holding on to water (fluid)? [If incorrect review] You can check for swelling in the legs which is also called edema Most patients will get swelling in the legs, but some patients can get swelling in their stomach. Have you ever had swelling in your stomach because of your heart? [Some people may say weigh themselves. Response: you are right, is there any other way?] 15 Which pill is your water pill? [If correct] Yes, that is the right one [may also allow bottle with Red mark or W on lid ] [If incorrect] No that isn t what I have

5 # QUESTIONS & SUPPLEMENTAL TEXT documented, has it changed recently? [Or] Look on page 7 in your workbook, the name of your water pill is written on this page twice () 16 Lets talk about how many pill you would take if your weight was up, What if you woke up tomorrow and your weight was [target wt + 5] pounds? What will you do? [If correct, patient should indicate upper yellow zone dose of water pill.] [If wrong] How did you decide on that amount? Do you have your weight card available? Let s walk through this together. Look at the weight column on your weight card. Do you see [Target +5] on your card? What color weight zone are you in? How many water pills are listed in that weight zone for morning? For afternoon? This is the number of water pills that you should take at this weight.

6 Medication Module # QUESTIONS & SUPPLEMENTAL TEXT Twice () 17 Refer to page 3 in your workbook How to Take Your Medications, so please get your bottle of water pills. Let s talk for a few minutes about your medications. Do you ever have trouble taking your medications? [If yes] what problems are you having taking your pills/medications? 18 What would you do if you think you are having side effects from your heart pills? Do not stop taking your pills. Instead, call and talk to your doctor for assistance or referral. 19 What will you do about taking your heart pills if you feel good? [If patient says they d stop or cut back] You should not stop your heart medication at anytime unless told to do so by your doctor. 20 What would you do if you have trouble paying for your heart pills? Don t stop taking your pills or change the way you take your pills. You need to call your doctor. Your doctor can assist you with suggestions to help you get your pills.

7 # QUESTIONS & SUPPLEMENTAL TEXT 21 Can you tell me how many refills you have left in your water pill bottle? Twice () [If 1 or more] Great! Remember not to let any of your medicines run out. This means not letting your refills get to Zero. [If Pt can t find refills] - Let s refer to page 4 in workbook [then have them look again] [If zero refer to next question] 22 What would you do if you do not have any refills left, or if you have run out of pills? Call your doctor or pharmacist right away to get more refills. 23 Do you have a system to help you remember how and when to take your heart pills? [If Yes] Great, could you tell me about it? [If No] What do you think may help you remember or keep you organized? Some patients keep a list of instructions for how many pills to take and what time of day. [My Daily Medications] Others use a pill box. Keep your pill bottles in a place that you can remember to take them. If you are going out of the house for a long time, carry enough heart pills with you. [Goal setting] - Which of these would you like to try and do? Exactly how (what/when/where?) will you do it? 24 Do you always take all your pills bottles to each doctor visit? [If Yes] Great!. [If No, address barrier/motivation]

8 # QUESTIONS & SUPPLEMENTAL TEXT 25 What do you and your doctor do with these bottles at the visit? Twice () It is important to show your doctor how you take your pills and when you take them. This helps your doctor keep you safer and make sure you do not run out of pills.

9 Salt Module # QUESTIONS & SUPPLEMENTAL TEXT Refer to Salt tab or page 9 in your workbook 26 What is sodium? Twice () Sodium is another name for salt. Any food that says sodium on the label has salt in it. Why is salt (sodium) bad for someone who has heart failure? Salt causes your body to hold on to water. Remember, salt is like a sponge. We have discussed some ways to eat less salt. Can you tell me some of those ways? Choose foods that are low in salt Don t add salt when you cook Take the salt shaker off the table, and don t add seasonings with salt to your food 29 Great. Let s talk more about how to buy foods that are low in salt. How can you tell whether something you buy has too much salt? Look at the label, If the label says less than 140 mg of sodium per serving, it is a good choice Remember to watch how much you eat. 30 Now, I want you to turn to the back of your workbook to handout Looking at Labels (Spanish) This shows some different labels from foods. Label 1 is from a bottle of Ranch salad dressing. How much sodium per serving does it have? [310mg / 2T] Is this a good one for you to buy? [No] Now look at label 2. This is from a different bottle of dressing. How much sodium per

10 # QUESTIONS & SUPPLEMENTAL TEXT serving does it have? [40mg/ 2T] Twice () Is this a good one for you to buy? [Yes] There are two more labels below. Label 3 and label 4 are both from vegetables. Which one is a good choice? Label 3 canned veg: 319mg/1/2 cup Label 4 frozen veg: 0 / 2/3 cup [If patient understands] So, looking at the label is important when you are learning what foods are high in salt, and you ve got this down. OR [If patient needs more practice] Looking at the label is important when you are learning what foods are high in salt. Practice this over the next few days, and we can spend more time on this next time we talk. [make note to review again on next call] 31 I m going to read a list of foods to you, and I want you to tell me which ones are high in salt. For the following list of foods, discuss success or failure such as in the following: That s right. Almost all the meats you get from the deli section are high in salt. Sometimes they say low salt, but they usually aren t. OR Actually, most salad dressings have a lot of salt. What are your favorite dressings? Oil and vinegar is OK. List #1 Educator use for first attempt Processed and smoked meats, like ham, sausage, or turkey like you buy from the deli section Seasoned rice (Rice A Roni) Eggs Barbecue sauce Lemons C heese

11 # QUESTIONS & SUPPLEMENTAL TEXT Fres h corn Instant hot cereal packet of oatmeal Fresh pork chops Two pieces of bread Canned tuna fish List #2 Educator use for second attempt Pizza Macaroni & Cheese Canned fruit Salad Dressing Saltine Crackers Low-fat yogurt Sausage Graham Crackers Grill ed fish Canned beans A frozen meal 32 Would you like to set a goal for yourself about eating less salt? Twice () Look at page 16 in your workbook 33 Now I want you to turn to page 15 in your workbook There is other information on food packages that show you which foods are safe for you to eat. The best label is Sodium Free. These foods have no salt. Foods that say No Salt Added are usually good too. How about foods that say lower sodium or reduced sodium? Are these OK? These are tricky. For example, lower sodium canned beans are still usually high in salt. So, you need to check the nutrition facts label to see how much salt there is in one serving. Remember to discuss this with the person who does the Shopping/Cooking and with spouse/partner 34 Knowing what foods are high in salt is only half the battle. You also need to know what you can eat instead!

12 # QUESTIONS & SUPPLEMENTAL TEXT Twice () I m going to read you a list of some foods or seasonings, and I want you to tell me what you could eat instead that would have less salt. Putting salt on vegetables Ketchup Fast food cheeseburger Fried c hicken Work on Salt Diet History Module

13 Exercise Module # QUESTIONS & SUPPLEMENTAL TEXT [VERIFY that MD has approved exercise for this patient] 35 Refer to Exercise Tab or page 17 in your workbook Twice () Is it OK to exercise with heart failure? [If yes, proceed to 36] [If not sure reinforce that exercise is generally safe] [If no, explore why they feel it is not safe] 36 How does exercise help people with heart failure? When you exercise regularly, you: a. have more energy b. feel better [Reinforcement] Your heart is a muscle. Like other muscles, it works better if you exercise it. 37 When is it not safe to exercise? You should stop exercising if you feel chest pain, dizziness or have severe shortness of breath. You should also stop if you have intolerable pain in your joints or feet Great, you seem to know the main benefits of exercising and what you need to do to be safe. Complete Exercise Plan and Goal Setting

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