Patricia Weaver, NP McLeod Outpatient Chronic Disease Clinic Dr., Your patient, Clinic.

,has been mentioned as a potential candidate for the Outpatient Chronic Disease

The Mission of this clinic for our heart failure patient is to: Educate patients and families about the etiology, natural history, and treatment of heart failure with the goal of education to incorporate patient self- management as much as possible. Improve the provision of guideline directed care. Reduce the amount of admissions and readmissions for HF exacerbations. Increase the length of patients lives whenever possible. Increase the quality of life through a program of nutrition, medicine, exercise, and advanced therapies. Scope of Services: 1. Procedures a. Comprehensive initial consultation which includes : Complete history and physical Medication history Quality of life assessment Functional assessment including 6 minute walk test Screening for depression Additional screening that is patient specific and may include screening for sleep apnea

b. Serial visits Interval of serial visits is dependent on patient symptoms Targeted ROS and problem focused Physical exam along with vital signs, 02 saturation, and weight measurement Individual and group teaching are included in serial visits

c. IV diuretic administration on an as-needed basis based on patient symptoms. This will include drawing of baseline labs ( BNP, BMP or CMP, Magnesium) and repletion of potassium and magnesium per protocol. 2. Additional Heart Failure Clinic functions and responsibilities and services: a. The clinic will identify knowledge deficits and initiate education according to baseline assessment and established guidelines. b. Management decisions will not be made without contacting the PCP and/or the primary cardiologist. c. The clinic will notify the referring provider of changes in lab values obtained by the clinic. d. The clinic will collaborate all care of the patient with the referring provider.

[Recipient Name] April 24, 2014 Page 2 e. If problems are identified that are not related to heart failure the patient will be referred to the PCP. f. The clinic will send progress notes to the referring provider. g. The clinic may request additional medical records from the referring provider to assist in continuous quality care. We hope to collaborate with you to provide the best care for your patients. If you agree to refer your patient to this program please sign this letter and return it to our office. We will contact the patient and arrange the initial visit.

Sincerely,

Patricia Weaver, NP

RESPONSE Signing this letter documents agreement to patient enrollment in the McLeod Outpatient Chronic Disease Clinic

Provider Signature

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