Domains of Heart Failure

Domains operate in all areas of human activity. In the broadest sense, a domain is any realm of interest, knowledge, or responsibility. Domains provide a framework for thinking, development, and performance. Applying the framework of domains to heart failure opens new possibilities for thinking about the care for those with heart failure. From carefully chosen domains, requirements or characteristics necessary for success can be derived. From the requisite characteristics, goals can be established. From the goals, specific tasks leading to achievement can be determined a measured.

How can domains of heart failure be chosen in a meaningful way? One approach is to use the Model for Improvement and ask, “What are we trying to accomplish?” The simple answer is “to improve the quality (and quantity) of life for individuals with heart failure while being good financial stewards.” This means that everything and everyone that “touches” a person with heart failure needs to be considered. With a human person (in this case a patient) at the center, mapping complex issues related to heart failure becomes somewhat less demanding. All patients originate from within the communities in which they live. This becomes the Community Domain. Nearly all patients with heart failure require hospital admission for their care at some point. This becomes the Hospital Domain. Who touches the patient includes the nurses, doctors, and others that deliver the care. This becomes the Clinician Domain. The type of care that is given falls under the Science Domain. Each of the four major domains intersects and overlaps with all the others forming a cohesive whole.

Community Domain
This is where people live. A person within the community crosses a threshold from “personhood” to “patienthood” when they are told they have heart failure. When an individual crosses this threshold, they take on a new identity, “heart failure patient,” an identity that they will take with them to the grave. With heart failure increasingly pervasive, a grass roots community response is needed to address the day-to-day needs of heart failure patients. Within the community, who and what touch the patient? Who and what do the patients touch? For example, the EMS operates in the Community Domain. This is also where insurance companies and governmental payors live as well. Employers, churches, the whole spectrum of community life fill this domain.

Hospital Domain
This is where people receive their care for heart failure when their heart begins to decompensate. With the index hospitalization, a new relationship is established between the hospital and the patient. It is likely that the patient will be readmitted at some point. It is also possible that the hospital will be where the patient dies. Hospitals need to understand that each time they “touch” a newly diagnosed patient with heart failure, a new relationship begins. Hospitals that recognize this relationship are doing a great service to their patients and the communities.

Clinician Domain
These are the individuals who care for the patients within the hospital and in the outpatient setting. The clinicians live in both domains: the community and the hospital. The clinicians have unique educational and competency needs related to heart failure. They also have an opportunity to serve as a bridge between day-to-day life within the community punctuated by the occasional need for hospital care, and potentially hospice care. The clinicians need to be integrated into the relationship between the hospital and the patient.

Science Domain
The Domain of Science describes what care is needed for the patients. Understanding the underlying pathophysiology of heart failure, applying proper diagnostic tools in a timely manner, and initiating treatment consistent with the actual care needed by the patient not only contributes to the well being of the patient, but also reduces resource demands upon the hospitals. The Domain of Science includes the wealth of knowledge in process improvement garnered over the past 100 years and shown to be highly effective throughout industry. Application of these time tested methods to clinical care processes has now been shown to work as well. The Domain of Science in Heart Failure provides for the marriage of clinical science based upon the peer-reviewed literature with process improvement methods that permit the orderly planning and implementation of new methods as well as improvement of existing processes of care.