HFSA National Heart Clinic Survey Question Title * 1. Clinic Information Clinic Name * Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Email Address * Phone Number * Question Title * 2. Clinic Location Urban Suburban Rural Question Title * 3. Type of Hospital Academic Tertiary Care Community Question Title * 4. EHR Vendor Vendor Name: Modules: Question Title * 5. What is the volume of patients in clinic and the volume of CHF patient hospital discharges per year? Volume of Patients: Discharges per year: Question Title * 6. What is the designation of your clinical director? MP MD APP None Other (please specify) Question Title * 7. Is there a Heart Failure Cardiologist in your program? Full-time Part-time No Question Title * 8. How many heart failure cardiologists are in your program? Question Title * 9. If there is a Heart Failure Cardiologist in your program, are they board certified? yes no Question Title * 10. Other Staff (please provide the number of corresponding staff members) RNs APPs Social Worker Dietary Pharmacy Psychology Question Title * 11. GDMT titration protocol On-Site Remote No Question Title * 12. Palliative Care Services On-Site Remote No Question Title * 13. Ability to do same day IV diuretic infusions On-site Remote No Question Title * 14. Standard functional status evaluation NYHA class 6 min walk CPET Other (please specify) None of the above Question Title * 15. Coronary Angiography on site Yes No Question Title * 16. Are you able to perform myocardial biopsy in your institution? Yes No Question Title * 17. Do you offer remote patient visits? Yes No Question Title * 18. Do you have a remote patient monitoring platform? Yes No If yes, what do you use? Question Title * 19. Do you routinely follow implantable cardiac diagnostics? Optivol Cardiomems Other (please specify) None Question Title * 20. Research Provider initiated Multi-center None Other (please specify) Question Title * 21. Research funding sources NIH RO1 None Other (please specify) Question Title * 22. Do you use patient-reported outcomes? Yes No If yes, what platform? Question Title * 23. Does your clinic have a standard mechanism to evaluate patients for advanced HF therapies? No Done by HF provider Done by multi-disciplinary team Question Title * 24. Transplantation Single organ Multi-organ Shared care No Question Title * 25. VAD Implanting center Shared care No Question Title * 26. Specialty cardiomyopathy center (select all that apply) HCM Genetic CM Amyloid Sarcoid None Question Title * 27. Genetic testing On-site Remote No Submit
