CHF Care Project: 
Improving Quality of Life for Chronic Heart Failure Patients through Advance Care Planning

Timely palliative and hospice care has been proven to improve the quality of patient care, symptom management and satisfaction, while decreasing healthcare expenditures for patients experiencing serious disease. Yet, these services remain under-used across the nation.  Heart failure (HF) is the number one principal discharge diagnosis in the Medicare population nationwide. People with Medicare who have HF have frequent emergency room visits and hospitalizations. Evidence demonstrates the importance of palliative and hospice care in improving quality of life and reducing inpatient and emergency room use in patients with HF near the end of their life.

About the Project

The CHF Care Project: Improving Quality of Life for Chronic Heart Failure Patients through Advance Care Planning is a Special Innovation Project (SIP) that convenes a learning and action network (LAN) through partnerships in Delaware, Louisiana and West Virginia within the following categories: hospitals, patients/family members, targeted primary care and cardiology clinicians, and partners and stakeholders. The LAN provides education, shares best practices, and develops evidence-based interventions to increase appropriate beneficiary referrals to palliative and hospice care. LAN interventions, based on needs identified through community root cause analysis, include:
  • Developing palliative care teams representing multiple health care settings that serve patients with HF in advanced disease stages as well as their families. These teams help patients manage symptoms, coordinate care across settings, clarify communication, and carry out informed, self-directed end-of-life care decisions.
  • Educating clinicians to foster high-quality conversations with patients and families about advance care planning. These conversations inform ongoing patient plans of care. With consent, the clinician can connect the patient with other providers and resources.
  • Improving competence in provision of basic palliative care for providers caring for patients with advanced serious illness. Competencies include communication skills, collaboration across multiple care settings, and symptom management.
As a result of provider, patient and family education, as well as patient self-advocacy, communities in this project will see increased palliative care and hospice referrals and fewer late referrals for hospice care. As a result of earlier referrals, we will see a reduction in hospital utilization and an improved quality of care.

Download our fact sheet

Watch our video - Palliative Care and Oranges: A Story About Managing Illness

Project Contacts


Jan Lennon
State Program Director
(877) 987-4687 ext. 7806   
Jami Jones
RN Project Coordinator
(877) 987-4687 ext. 116 


Kym Herrin
Quality Improvement Specialist
(225) 248-7068


Carla VanWyck     
State Program Director     
(800) 642-8686 ext. 4221      
Biddy Smith 
Network Task Lead
(800) 642-8686 ext. 3252

Delaware Medical Orders for Scope of Treatment (DMOST)

In Delaware the DMOST from is used. DMOST stands for Delaware Medical Orders for Scope of Treatment.  The DMOST is a clinical process to facilitate communication between health care professionals and a patient living with a serious illness or frailty whose health care practitioner would not be surprised if the patient died within the next year, or if  the patient lacks medical decision making.  The DMOST is voluntary and is not an advance health-care directive. It is intended to provide direction to emergency care personnel regarding the use of emergency care and to health care providers regarding the use of life-sustaining treatment by indicating the patient’s preferences concerning the scope of treatment, the use of specified interventions, and the intensity of treatment for each intervention.

The DMOST is a physician order and intended to accompany the patient, and to be honored by all personnel attending the patient, across the full range of possible health care settings including but not limited to the patient’s home, a health care institution, at the scene of a medical emergency, or during transport.

Louisiana Physician Orders for Scope of Treatment (LaPOST)

Louisiana Physician Orders for Scope of Treatment  known as LaPOST is an easily identifiable gold document that translates a patient’ s goals of care and treatment preferences into a physician order that transfers across health care settings. In Louisiana the LaPOST does not replace an Advance Health Care Directive but can be used to operationalize the directives of the living will, as well as complement the Advance Health Care Directive. The LaPOST is the first statewide, uniform physician order that is recognized across care settings in Louisiana. The LaPOST travels with the patient when they move from one residential or medical setting to another, it ensures that the physician orders travel with them. LaPost provides clear direction about a patient’s health care treatment wishes for physicians, nurses, emergency responders and other health care providers wherever they are.

Conversation with the patient about the type of care they would like to receive as their disease progresses is important. The LaPOST provides the context for guiding the conversation and makes it more likely that patient’s will express their treatment wishes and goals of care. The completion of the LaPOST involves a thorough discussion between patients and physicians with the physician being responsible for completing this document.

West Virginia Center for End-of-Life Care

Established in 2002 by the WV Legislature, the West Virginia Center for End-of-Life Care provides coordination, education, and resources so that West Virginians will 1) have their preferences for care at the end of life identified and respected through advance care planning, 2) die in the setting of their choice with the option of palliative care and hospice, and 3) die comfortably with the availability of appropriate pain and symptom management.

Additional Resources for Providers

Additional Resources for Patients