Standardising heart failure care for better outcomes

Heart fail­ure remains a major health issue in Australia. 

It con­tributes to near­ly one in 50 deaths each year and is the most com­mon rea­son peo­ple over 65 end up in hos­pi­tal. What makes this even more con­cern­ing is that almost one in four patients hos­pi­talised with heart fail­ure are read­mit­ted with­in 30 days of going home. 

These num­bers high­light a clear gap: peo­ple liv­ing with heart fail­ure need bet­ter sup­port and more coor­di­nat­ed care to main­tain sta­bil­i­ty, reduce avoid­able dete­ri­o­ra­tion, and improve their over­all recov­ery and qual­i­ty of life 

South Aus­tralia already has Mul­ti­dis­ci­pli­nary Heart Fail­ure Man­age­ment Pro­grams (HFMPs) in place. These are run by teams of health­care pro­fes­sion­als work­ing togeth­er. There’s strong evi­dence that this type of mul­ti­dis­ci­pli­nary care improves patient out­comes, includ­ing self-report­ed health, and reduces the risk of urgent care needs, hos­pi­tal­i­sa­tion, and even death.

A new frame­work for con­sis­tent, high-qual­i­ty care

The Car­diac Care Statewide Clin­i­cal Net­work (SCN) has released the Chron­ic Heart Fail­ure Man­age­ment Pro­gram mod­el of care (PDF 551KB) (HFMP MoC) – a prac­ti­cal guide for how heart fail­ure ser­vices should be set up and run across South Australia. 

The HFMP MoC has been devel­oped so all patients with symp­to­matic heart fail­ure have equal and time­ly access to appro­pri­ate spe­cial­ist med­ical review and man­age­ment, as well as coor­di­nat­ed nurs­ing and allied health care across South Australia. 

The mod­el cov­ers key areas including: 

• Spe­cial­ist med­ical review and ongo­ing management 

• Heart fail­ure mul­ti­dis­ci­pli­nary ser­vices structure 

• Tim­ing of sup­port: from home to hospital 

• Refer­rals and inclu­sion criteria 

• Patient assess­ment and management 

• Man­ag­ing decompensation 

• Dis­charge criteria 

• Bench­mark­ing and outcomes 

• Work­force lev­els, skill mix and roles.

These ele­ments aim to reduce vari­a­tion across ser­vices and increase patient access to spe­cial­ist clin­i­cians regard­less of location. 

The Car­diac Care SCN would like to thank all the stake­hold­ers who con­tributed their time, knowl­edge, and feed­back to devel­op this mod­el of care and con­tin­ue to sup­port efforts to improve care deliv­ery and patient outcomes. 

Find out more 

To learn more about the Chron­ic Heart Fail­ure Man­age­ment Pro­gram mod­el of care and heart health, vis­it the SA Health car­diac care web­page.