III. Management (54 items)

A. Advise patient and/or caregiver on guideline directed medical therapy and self-care plan.

B. Demonstrate knowledge of social determinants and barriers to implementation of appropriate HF management.

C. Assess patient eligibility for advanced therapies.

D. Assess patient eligibility for hospice care coordination.

E. Assess patient eligibility for recognition of futility in care.

D. Evaluate risk of HF decompensation in patients with atrial fibrillation.

F. Participate in shared decision-making and advanced directives.

G. Coordinate patient, caregiver, and/or surrogate to implement discharge plan.

H. Coordinate palliative care for HF patients (e.g. counseling, cultural activities, homecare, medication to reduce pain/suffering, patient education, spiritual activities).

I. Determine the effectiveness of the plan of treatment and care based on outcomes by assessing patient response(s).

J. Determine the effectiveness of the plan of treatment and care based on outcomes by collecting additional subjective and/or objective information as needed.

K. Recognize the importance of health-related quality of life (HRQOL) in patients with HF (e.g. cognitive dysfunction, chronic alcoholism, depression, symptom burden, functional status).

L. Establish a patient-centered treatment and care plan that includes considering comorbidities.

M. Establish a patient-centered treatment and care plan that includes making referrals to other health professionals and community resources.

N. Establish a patient-centered treatment and care plan that includes ordering, performing, supervising, or interpreting results of further tests.

O. Establish a patient-centered treatment and care plan that includes prescribing, ordering, or administering non-pharmacologic therapies and/or procedures.

P. Establish a patient-centered treatment and care plan that includes prescribing, ordering, or administering pharmacological therapies.

Q. Establish a patient-centered treatment and care plan that includes providing for appropriate follow-up.

R. Establish a patient-centered treatment and care plan that includes providing relevant education and/or counseling.

S. Evaluate the mechanisms of action, pharmacologic features, and dosing of existing and new agents for treating and managing HF.

T. Identify drug-drug and drug-disease interactions.

U. Recognize appropriate use criteria of specialized procedures specific to a given population(s) (e.g. endomyocardial biopsy, CPX).

V. Provide education and or counseling for HF patients (e.g. diet/fluid intake, self-management, self-monitoring, weight).

W. Utilize in-patient physical and occupational therapy for HF.

IV. Systems of Healthcare (10 items)

A. Demonstrate knowledge of quality, safety, performance, value measures, and ethics in HF.

B. Apply culturally sensitive methods with transitioning HF patients.

C. Comply with Core Measures and best practice standards.

D. Develop administrative roles, policies, and protocols for HF treatment and diagnosis.

E. Participate in the development of formal and informal educational programs for approp

riate health care professionals.