Shore Population Health congestive heart failure

The Population Health Team offers a special program for patients diagnosed with congestive heart failure (CHF). The program helps people manage their CHF at home.

CHF Program Benefits

The CHF program is a 60-day program conducted by phone. Patients work with our transitional nurse navigators (TNNs) who provide information and support to manage heart failure. 

The TNNs: 

  • Give guidance on medications, diet, fluid intake and exercise, based on what is outlined in the University of Maryland Medical System’s Heart Failure Handbook
  • Monitor the patient’s condition
  • Collaborate with other members of the health care team, such as rehabilitation therapists who provide occupational, physical or cardiac rehab
  • Help patients complete advance directives, which state how a patient wants their care handled when they are not able to participate fully in conversations with their care team
  • Provide a referral for a Palliative Care consult, when appropriate

Patients who need remote monitoring devices (blood pressure cuffs, scales and pulse oximeters) receive them early in the program. They get training on how to use these devices and keep a record of the data they provide.

Enrollment in the CHF Program

Patients are identified as candidates for the CHF program prior to getting discharged from inpatient care at UM Shore Medical Centers at Chestertown and Easton and from all four UM Shore Regional Health emergency departments. They are screened for the presence of chronic diseases (including COPD, heart failure and diabetes) that would make them "high-risk for readmission" based on hospital and/or emergency department use, medical complexity and medication non-compliance. Patients who meet the CHF program criteria are assigned to a TNN. 

To learn more about the CHF Program, contact Jessica Denny, PT, DPT, at 410-829-5504 or