Care Transitions for People with Heart Failure: Optimizing Facility Processes and Patient Outcomes

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Upon completing this session, participants will be able to:

  • Explain strategies for and the value of effective communication between clinicians at various settings of care when transferring a patient with heart failure
  • Summarize examples of evidence-based assessment tools used to facilitate a transition between settings for patients with heart failure
  • Describe the benefits of integrating operational processes for transitioning patients with heart failure between settings of care
  • Recognize how the integration of facility processes around transitions of care for patients with heart failure can reduce hospital re-admissions and other adverse outcomes

Sharon Huerta

Sharon Huerta is an Advanced Practice Registered Nurse with a drive for improving patient outcomes and compassionate patient care. She is a Clinical Nurse Specialist with a Doctor of Nursing Practice degree from Johns Hopkins University and a specialization in Heart Failure Program Management. Currently, she serves with an exceptional multidisciplinary team at Baptist Memorial Hospital in Memphis, Tennessee as the leader of the Heart Failure Program.

Under Sharon's leadership, Baptist Memorial Hospital was awarded the prestigious Get with the Guidelines-Heart Failure Gold Plus award and achieved Heart Failure Accreditation through the American College of Cardiology.

Outside of her professional life, Sharon spends her spare time training for running races, traveling, and reading as much as possible.

Nicole Orr, MD, FACC

Cardiologist/Assistant Professor/Founder PACC

Post-Acute Cardiology Care, LCC

Nicole Orr, MD, FACC is an Assistant Professor of Medicine in the Division of Cardiology at Tufts University School of Medicine, and the founder/president of Post-Acute Cardiology Care. Her work is dedicated to developing HF disease management programs in SNFs, with an emphasis on educating staff on navigating the complexities of treating this high-risk demographic. She leads several SNF based Heart Failure programs in CT speaks nationally about optimizing treatment of geriatric cardiology patients admitted to PALTC, has published on best practices for PALTC HF management, and serves on the AMDA Clinical Practice Steering Committee and multiple writing groups.

Sing Palat, MD, CMD

Medical Director

Optum Senior Community Care

Sing Palat MD, CMD is a Medical Director with Optum Senior Community Care and Associate Clinical Professor at the University of Colorado Division of Geriatrics. She enjoys working with interdisciplinary teams in the care of vulnerable older adults. Dr. Palat is the President of CMDA The Colorado Society for Post-Acute and Long-Term Care Medicine and has served on the Board of Directors for AMDA.
  • 1.0 CME
  • 1.0 CMD Management
Credit Statements

Release: 3/7/2025  |  Expiration: 3/6/2027

Accreditation: Post-Acute and Long-Term Care Medical Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

CME Designation: Post-Acute and Long-Term Care Medical Association designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CMD Credit Hours: This CME activity has been pre-approved for up to 1.0 management hour(s) toward certification or recertification as a Certified Medical Director (CMD) in post-acute and long-term care medicine. Each physician should claim only those hours of credit actually spent on the activity. The CMD Program is administered by PALTmed. For further information, contact PALTmed at 410-992-3115 or at certification@paltmed.org.

Financial Disclosure Statement

No one in control of content disclosed any relevant financial relationships with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Components visible upon registration.