Integrated clinical paths have been used in heart failure patient care for years because of a simple reason: they work. Many studies have shown that an integrated approach to heart failure management—including primary and secondary care, plus support and social services—have shown that this model results in improved quality of life, symptom control, and self-management, plus potential cost savings.[1]

Clinical care paths include many components, from prescribing patterns to discharge transition and multidisciplinary patient education that supports the patient throughout their care journey. As with other chronic conditions like COPD and diabetes, incorporating integrated patient education care plans into the clinical care path plays a crucial role in patient outcomes. As a result, a number of innovative strategies are being studied to improve delivery of patient education. Some of these include:

  1. Development of app-, email-, or online-based patient education care plans. A number of leading organizations, including the American Heart Association and The Wellness Network, are developing or have launched heart failure education programs that are designed to follow patients from the in-patient setting to discharge to chronic care management and even into rehab. In a truly integrated education care plan, these novel programs deliver customized education in a variety of formats while also collecting valuable patient data such as symptom progression and key biometrics that can be communicated back to the care team for remote management.
  2. Increasing use of the teach-back method. This approach, sometimes called the show-me method, helps demonstrate patient understanding by asking patients to “teach back” the material they just learned to a nurse or practitioner. While a number of recent studies have shown that it works,[2] adoption rates can be low because it’s a time-intensive approach for nursing staffs that are already stretched. Ideally, teach-back questions should be included in the plan design, to make it easier for nurses to use this approach.

Among these, the use of specially designed education care plans is especially well suited for integration into clinical care paths. A well-designed education care plan can support a patient at every stage of their care. A well-designed care plan offers bundled education that is delivered at the moment the patient needs it, is customized to the patient’s condition, follows national guidelines, aligns with a hospital’s clinical protocols, is easily accessible to all patients, and allows for healthcare providers to track patient interaction and compliance.


[1] MacInnes J, Williams L. A review of integrated heart failure care. Prim Health Care Res Dev. 2018 Jun 18:1-8.

[2] Ha Dinh TT, Bonner A, Clark R, Ramsbotham J, Hines S. The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review. JBI Database System Rev Implement Rep. 2016 Jan;14(1):210-47.