Heart Failure and Cardiac Care at Home

Care by condition

Heart failure is the condition that sends people back to hospital more often than almost any other, and most of those readmissions build slowly over days. Two kilograms gained in three days, shoes that no longer fit, a third pillow needed at night — the warning signs are visible at home long before they become an emergency department visit.

The value of home care in heart failure is that somebody is looking. Not treating — looking, and saying something early enough for it to matter.

What actually changes at home

• Weighing daily becomes a medical act. Same scale, same time, same clothing. A steady gain is fluid, not food, and it is the earliest warning there is.
• Salt is everywhere. Most of it is not in the salt shaker — it is in bread, deli meat, canned soup and takeaway.
• Medication lists get long, and diuretics reshape a day around the bathroom.
• Breathlessness dictates pace. Stairs, showering and dressing all cost more than they used to.
• Fear is part of it. People who have had a heart attack are often frightened to exert themselves at all, which causes its own decline.

How we help

• Daily weights recorded properly and reported when they trend up — the single most useful thing anyone does in heart failure
• Watching for the other signs: swelling in ankles and legs, new breathlessness lying flat, needing more pillows, a cough that will not settle
• Low-sodium meals that are actually worth eating, and help reading labels while shopping
• Medication reminders and routines that fit around diuretics rather than fighting them
• Pacing help with washing, dressing and stairs, so effort is spread across the day
• Encouragement to stay active within the limits cardiac rehabilitation has set, which is the opposite of what fear tells people to do
• Getting to cardiology, cardiac rehabilitation and family doctor appointments
• Nursing where a care plan includes it

Who provides the care

Personal support workers provide the daily support and the monitoring. Where a plan includes nursing tasks, we place an RN or RPN. Nobody we send diagnoses or changes treatment — the value is early, accurate reporting to the people who do.

Common questions

Can you actually stop a hospital readmission?

We cannot promise that, and we would not. What we can do is make sure the daily weight is taken, the swelling is noticed, and somebody phones the family doctor or heart function clinic on day two rather than day six. That is where the difference is made.

Who gets told when something changes?

Whoever you tell us to, and we agree it before we start — usually the family and the family doctor or heart function clinic. Nothing gets noticed and then sat on.

Can you cook to a low-sodium diet?

Yes, and it is worth taking seriously. Food that follows the diet but nobody wants to eat leads to people not eating, which causes its own problems.

My mother is frightened to move since her heart attack. Can you help with that?

Yes, gently. Where cardiac rehabilitation has set what she can safely do, having someone alongside for the first weeks is often what gets a person moving again.

Is this publicly funded?

It may be. Ontario Health atHome arranges publicly funded personal support and nursing for people who qualify, and many hospitals run heart function clinics with their own follow-up. Ask about both before paying for private hours.

Where we provide this care

We provide this support across communities across Ontario, from the Greater Toronto Area to Thunder Bay. If your town is not listed, call us — we will tell you honestly whether we can staff it properly rather than promising and then failing to turn up.

Related

• COPD and respiratory
• Kidney disease and dialysis
• Autism — children and adults
• Home care — what it covers
• Respite care for family carers
• 24-hour home care
• All the communities we serve