Improving Symptoms and Quality of Life in Chronic Heart Failure: Pilot Study

The investigators will examine the feasibility of two palliative care interventions designed
to improve different facets of quality of life. Briefly, the two interventions are:

1. A palliative symptom management and psychosocial care intervention named Collaborative
Care to Alleviate Symptoms and Adjust to Illness (CASA) that includes

1. evidence-based palliative symptom management of breathlessness, fatigue, and pain,
provided by a nurse;

2. a 6-session structured psychosocial care protocol targeting depression and
adjustment to illness, supplemented by informal (family) caregiver assessment and
support, provided by a social worker or psychologist; and

3. brief weekly team meetings with the nurse, social worker/psychologist and a
palliative care specialist, cardiologist, and primary care provider.

2. A psychospiritual intervention that is home-based, self-guided, and requires minimal
resources. It will be delivered in written modular form via US Mail along with brief
weekly telephone support.

The specific aims of the study are to:

1. Examine intervention feasibility and determine preliminary estimates of intervention
effect

1. Determine patient participation rates and cohort retention

2. Conduct a preliminary assessment of outcomes by measuring pre-post changes in
quality of life, depressive symptoms, health status, life meaning, and
spirituality.

2. Obtain qualitative feedback from study participants, the persons providing the
intervention, and providers/leaders in primary care, mental health, palliative care,
chaplaincy, and hospital operations.

Inclusion Criteria:

- eligible veterans from the Denver VAMC will have a prior primary discharge diagnosis
of heart failure in the last year,

- be at least 18 years of age, able to read and understand English,

- have consistent access to a telephone

- at least one of the following:

1. Kansas City Cardiomyopathy Questionnaire (KCCQ) score less than or equal to 60;

2. a second hospitalization for with a primary discharge diagnosis of heart failure
in the last year;

3. taking at least 80 mg oral furosemide (or equivalent) daily in a single or
divided dose for at least 2 weeks;

4. BNP greater than or equal to 250 or NT-proBNP greater than or equal to 1000; or

5. estimated creatinine clearance 30-80 mL/min.

Exclusion Criteria:

- previous diagnosis of dementia;

- active substance abuse, defined as an AUDIT-C score greater than 7, two positive
responses on substance abuse screening questions, or medical records indicating active
substance abuse or dependence;

- comorbid metastatic cancer, given the focus on heart failure palliative care;

- nursing home resident; and

- diagnosis of bipolar disorder or schizophrenia.