Person completing form _____________________
(signature/initials)      

Heart Function Program In-home/Telephone Screening Guide 

Initial Contact:  Patient/Family/Other ______________________________________________________________________
1.	Introduce yourself (see sample script)
2.	Verbal consent for telephone/video check in call:      Yes      No   
3.	Inform patient/family member that information may be requested from or provided to the primary care provider and/or pharmacy.

Surveillance screening (COVID-19): (If YES to any of the below) -> please call the primary care provider
□	Do they have fever and/or cough or difficulty breathing AND have travelled outside of Canada within the past 14 days before onset of illness?
□	Have they had close contact with a confirmed or probable case of COVID-19?
□	Have they had close contact with a person with acute respiratory illness who has been to the impacted areas within 14 days prior to their illness onset? 	

Heart Function Status	Yes	No	
New changes in symptoms of Heart Failure:(PND ,SOB , NYHA, Edema etc)?			
Is the patient checking their weights/BP/Pulse?			
Is there any changes in their weights( > 4llbs over 2 days or > 5llbs in one week)/BP/Pulse ?			
Has the patient had recent medication changes ?			
Has the patient had recent bloodwork?			
Has the patient had any other cardiac testing?			
Are there any pending cardiac tests that need to be completed with the next month?			
Does the patient have a diuretic Sliding Scale?			
Does the patient/caregiver understand how to use the diuretic sliding scale( teach back)?			
Do they have all of their current medications that they require?			
Do they have a plan in place in the event they run out of medication?			
If they had assistance with medication administration, do they still have that assistance?			
Does the patient have follow up through other specialist( Diabetes Education Center, Kidney Care Center etc)?			
Does the patient/caregiver understand when to contact the HF program, primary care or 911?			
Does the patient/caregiver understand current recommendations from public health re: social distancing and if applicable self monitoring and self isolation?			
Potential for Social Isolation			
Have family/friends checked on them recently?			
Is there somebody that can check on them?			
How often will they be checked on?_________________________________			
Do they currently receive homecare or community support services(paramedicine, telehomecare etc)			
Do they have enough groceries or a way of obtaining them?			
Other: Do you  have any other concerns about their wellbeing currently?(Describe)
____________________________________________________________________________________________________
If there were any social concerns -Would we have your consent to pass their information on in the event that a community resource might become available e.g., to help with food, medications etc. (Yes/No)	
Current care plan for heart function management/supports involved:
Family/Others ____________________     Primary Care Provider ____________________     HCC ____________________
Issue/Plan:	
Response -  Priority:   Urgent     Not urgent
Identified Need:  ___________________________________________________________________________________
Linkage with resources:  yes/no (describe)__________________________________________________
HF program RN follow-up:      yes/no                    Location (circle): clinic/ home/ video/ telephone  Date:
Physician (e.g) In person/telephone/virtual visit required:  yes/no (name/ date)___________________________________	

Mar 17, 2020

 Follow-up Date:  ________________________  Team Member Name:  _________________________________________