Delivering a Healthy WA
WA Health Conference and Awards

Strong partnerships in health – strengthening post-discharge management of heart failure through community-based surveillance and support

Day two – Wednesday 20 November 2013
12.05pm – 1.05pm Concurrent session 5

Heart failure (HF) results in the high use of health resources. The greatest cost contributor is hospital admissions; nearly 4000 separations annually, with a mean length of stay of 7.73 days. (HF Model of Care, WA Health). The majority of these occur in patients with a prior admission for HF. With improved post-discharge support, many readmissions may be preventable.

In 2011, the South Metropolitan Health Service convened a steering group of clinicians from Royal Perth, Rockingham and Fremantle to design an integrated service model (SmartHeart) linking patients with HF to specialist nurse support in primary care, the first of its kind in WA. Case Finders were appointed at Royal Perth and Fremantle Hospitals to ensure appropriate identification and referral of patients for the initial phase.

Curtin University was contracted to deliver nurse-led care management from April 2013 through a clinic in Bentley, phone follow-up, and home visits. Exercise was offered through Community Physiotherapy Services. To improve accessibility, outreach clinics were established in Cockburn and through a mobile health service visiting Kwinana, Mandurah and Rockingham. Patients enrolled in SmartHeart receive HF management education, a HF action plan (for early identification and treatment of clinical deterioration) and a care management plan. The patient's GP is engaged throughout.

During the first three months of the program, 136 patients were referred to SmartHeart. Patients from general medical wards made up 53 per cent of referrals. Patients engaged reported reduced anxiety and improved capacity to manage their condition.

SmartHeart provides an example of how collaboration across an Area Health Service and with a community partner can facilitate HF management in primary care. This is especially relevant to patients discharged from general medical wards who may not receive HF specific education. This model could readily be applied to other chronic conditions requiring care-management.

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