Download ACI_Maitland_hfmodel_v3

PROPOSAL FOR LOWER HUNTER CLUSTER
INTREGRATED CARE HEART FAILURE SERVICE PROVISION
Background
“CHF is a disabling and deadly condition that directly affects more than 300,000 Australians at any one time.
Regardless of patients’ clinical status (around one-third are hospitalised each year), the presence of CHF
requires complex management and treatment protocols that place pressure on both the patient and their
family/caregivers”
National Heart Foundation Australia 2010
Management of patients with chronic heart failure varies across the healthcare continuum, due to resourcing and
availability of expertise. The National Heart Foundation of Australia (2010) recognise and support the application of
various multidisciplinary models in the management of CHF, highlighting the benefits of structured CHF Programs or
Hospital Based Clinics interfacing with Primary Healthcare providers to achieve optimal outcomes for patients with CHF
across the continuum.
Current Data Admissions/Readmissions
157 July 2009 to June 2010
137 July 2008 to June 2009
Readmission data from the BHI will not be available to publish until Feb 2012, although we will have
some preliminary data for the teleconference meeting next week.
Patient Interview Data
TO BE ADDED
Overview of Proposed Integrated Model
NYHA Class I, II
Connecting Care**
<65yrs of age
High risk of admission
Deemed to require
specialist review
Worsening symptoms*
* Exception: Emergent symptoms requiring hospitalisation
** Connecting
Care to coordinate other community
and allied health services as appropriate
Complicated
Unable to attend
Cardiac Rehabilitation
psychosocial issues
clinic
or co-morbidities
NYHA Class III,
IV
Inpatient or able
to attend clinic
The CHF specific integrated model of care is supported by appropriate referral to local community and facility based multidisciplinary team (via
existing referral pathways) to address identified co-morbidities and special needs. This may include aboriginal health worker, multicultural health
Home Visit/occupational therapist, speech pathologist,
worker, dietician, psychologist, psychiatrist, social worker, physiotherapist, exercise physiologist,
telephone
pharmacist,
local
rehabilitation,
chronic
care
and
palliative
care
services.
The
specialist
team provides CHF specific mentoring
clinical advice to
General Practitioner
Acuteand
Cardiology
support
theManagement
multidisciplinary team as required to ensure optimal patient outcomes.
Clinic
Therapy optimised,
 Any patient with NYHA Class I, II may be referred to the Acute Hospital Cardiac Clinic where deemed necessary by the patients GP
symptoms
N.B. Current NHF (2011) guidelines recommend specialist opinion for all patients with CHF regardless of NYHA Class and should
controlled, patient
be considered as part of the patients management plan
stable
 At risk patients (According to NHF Guidelines) will be investigated for evidence of LV dysfunction by way of echocardiogram
through General Practitioner/Connected Care Program to ensure early diagnosis and optimal management
Patient remains
Clinical support from
unstable despite
Palliative Pathway
Acute Cardiology
maximum
Tertiary centre –
Clinic (peer phone
tolerated therapy
screening for
support)
advanced
cardiology
interventions



Patients may be recruited/identified in either the Primary Care setting or Hospital, highlighting the importance of prevention of
deterioration and hospitalisation
Flexibility in regards to the care modality patients access should be recognised as patients service needs may vary throughout the
ongoing case management process
Information regarding patient review and management will be available and communicated between GP/ Connected Care and Acute
Cardiology Programs via the electronic health record (suitable program/system yet to be determined by group)
Sources of Referral
 Medical/nursing staff to consider suitability of patients for HFLN service as soon as possible after admission and when diagnosis
confirmed
 Referral/Initial Assessment form to be fully completed by the Inpatient Cardiac Rehabilitation Liaison Nurse for hospital inpatients
 Referrals may also come from the General Practitioner/GP Connected Care Nurse for those patients who have been missed as inpatients
or who have been admitted to a hospital out of their residential area and therefore not referred in the usual way.
 Primary care referrals can also be made for patients whose heart failure is becoming unstable/ and or who require initial review/ support
to prevent hospital admission as per the flow diagram.
Inclusion Criteria
 All patients who preferably have had at least one recent hospital admission with a confirmed diagnosis of heart failure as determined by
echocardiography or coronary angiography / ventriculography or
Patients identified through their GP/Connected Care program who are; under 65 years of age, or deemed to require specialist input, or
have worsening symptoms with a confirmed diagnosis of heart failure as determined by echocardiography or coronary
angiography/ventriculography
 Complex Cardiac patients whom frequently represent to Hospital with Cardiac related problems and are assessed and considered
appropriate
Exclusion Criteria
< 18 years of age
Unwillingness to receive the additional support
Impaired cognitive ability (determined by the Mini-Mental State test) without carers to assist with self management
Major communication problems with both the patient and carer
Other life-threatening illness requiring palliative care (advanced malignancy)
Patient is in terminal stages of other debilitating illness e.g. advanced malignancy, end-stage renal failure, advanced COPD and this, not heart
failure, is their main problem
Acute MI already under care of cardiac rehabilitation services (unless patient has previously had input from the HFNS service)
Patient lives outside the Lower Hunter catchment area (See Appendix A) (to be referred to other equivalent services)
Acute/Hospital Service
Currently there is no capacity to offer an Acute/Hospital Based service to provide initial review for the relevant Class I and II patients as
indicated by diagram 1, or for the management of Class III and IV patients.
Given the service area, and intake numbers from the previous heart failure service at Maitland, it is anticipated that a 1.0FTE CNS (with
potential for CNS 2) would be required to successfully initiate and manage the Acute/Hospital service.
Initial Assessment
•
Medical History
•
Details of admission to Hospital
•
Eligibility criteria for service (includes most recent EF)
•
Physical assessment – JVP, Lung auscultation, Oedema, Weight, BP, BMI
Heart sounds
•
Signs and symptoms; chest pain, SOB, palpitations, sleeping patterns,
exercise tolerance, appetite, bowel patterns, NYHA grading
•
•
ECG, CXR
Screening for precipitating or exacerbating factors such as ischaemia, arrhythmias, valvular dysfunction, non-compliance with prescribed
therapy, unrestricted salt and fluid intake, infection, renal failure, anaemia, pulmonary embolus, thyroid dysfunction, use of contraindicated medicines [1]
•
Immunisation status, current medications (incl. Meds ceased in Hospital)
•
Recent pathology UECS, FBC, INR, Cholesterol, LFTs, Glucose, TSH, BNP
•
Psychosocial assessment (including carer when appropriate) – health literacy, cognition, depression/anxiety, social support
•
High risk/special needs screening – CALD, ATSI, two or more of the following: >65yrs of age, NYHA III or IV, significant
comorbidities, LVEF< 30%, lives alone, geographically isolated, depression, low socioeconomic status, significant renal dysfunction
(GFR ,60mL/min/1.73m2)[1]
•
Self management assessment – daily weighs, reduce salt intake, exercise, recognising symptoms, medication compliance, patient and/or
carer capacity to sustain self-management and symptom monitoring
•
Personalised plan of care developed including personalised action plan
•
Review of palliative care needs addressed in accordance with ‘Standards for providing quality palliative care to all Australians’ and NSW
Ministry of Health Policy number GL2005_056 ‘Using Advanced Care Directives (NSW) including advanced care planning [2, 3]
•
Provision of contact details clearly indicating appropriate levels of clinical review and how to access this based on self-monitoring and in
response to deterioration (such as GP number and when to contact, Clinic number and when to contact, and advice on when to call ‘000’)
•
Provision of appropriate patient education material (NHFA booklet ‘Living well with chronic heart failure’, and DVD ‘Simple steps for
heart health – managing heart failure’ both available in multiple languages, as well as the ATSI resource ‘Living every day with my heart
failure’ booklet. Both booklets include action plans)
•
Care plan (including action plan and advanced care planning, special needs of patient, ATSI/CALD status) clearly documented and
communicated to all team members.
Ongoing Assessment

Catered to individual patients needs

Usually weekly home visit for patients requiring the support and monitoring

Includes assessment as per initial assessment

Coordinating and monitoring titration of medications

Collecting bloods if indicated/requested

Summary of each visit sent to GP identifying any issues for review (telephone contact made where relevant/indicated)

Personalised plan of care reviewed and adjusted as necessary (including action plan and flexible diuretic regimen as appropriate)

Referral for home medicines review as appropriate

Provision of personalized medicines list

Review of palliative care needs at each change in clinical status (including discussion of advanced care planning as appropriate)
Proposed Program evaluation and Key Performance Indicators

Reduction in overall readmission rates for patients with heart failure at the Maitland Hospital

Objective measure of improvement in heart failure symptoms using the Minnesota Living with Heart Failure Questionnaire at Initial
assessment, 3 months, 6 months and as deemed required thereafter

Enrolment figures of at least 80% of eligible patients in the program from those identified (? Ability to identify patients from admission /
readmission data)

Time from Discharge/Post discharge/ Community Referral to initial phone contact of 5 working days

Compliance with guidelines re medication. Their standard assessment requires them to document the reason i.e. why any individual
patient is not on recommended target therapy
Discharge from Heart Failure Service (to Primary Care team or self management where appropriate)

Symptoms stable for a reasonable period of time

Deemed to have no ongoing educational needs relating to self management, lifestyle changes and understanding of condition

Adequate social support has been arranged for socially isolated or dependent patients

Adequate long term monitoring is able to be provided by GP surgery or district nursing teams (for housebound patients)

Ongoing monitoring provided by other health care service (connecting care, rehab, Palliative Care when appropriate) who will refer back
as required

Patient has indicated they no longer wish to have regular contact with the service
NB Patients and carers may still have contact with the service via the clinic, by telephone if considered necessary, readmitted patients are reassessed
for the service
Primary Care
An opportunity exists to utilise current GP Connected Care services to manage the group of patients - Connected care program to advise
desired model
LOCAL GOVERNMENT AREA – LOWER HUNTER CLUSTER
http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0007/58984/Maitland_Local_Area.pdf
1.
2.
3.
National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (Chronic Heart Failure Guidelines Expert
Writing Panel), Guidelines for the prevention, detection and management of chronic heart failure in Australia, updated July 2011. 2011.
NSW Department of Health, Using Advanced Care Directives (NSW), Research Ethics and Public Health Training, Editor. 2005, NSW
Department of Health,: Sydney.
Palliative Care Australia, Standards for providing quality palliative care to all Australians. 2005, Palliative Care Australia,: Canberra.