Safety in failure: Enhancing patient experience, care and outcomes in heart failure.

Abstract

Grampians Health Ballarat is a large regional health service in Victoria. Heart failure (HF) admissions represent a significant health and economic burden across the region. There was no existing structured care pathway or inpatient HF service. A new patient-centred, evidence-based HF model of care (MOC) was introduced through Safer Care Victoria’s (SCV) HF collaborative. In order to sustain the MOC, the interventions included a new multidisciplinary HF consult team and HF nurse practitioner, and expanded community support services such as HARP (Hospital at Risk of readmission Program) and cardiac rehabilitation (CR). It is based on the Heart Foundation’s “Five Steps To A Safe HF Discharge”, which include patient education on HF signs and symptoms, medication adherence, and a HF action plan, medical review within 7 days of discharge, and referrals to CR. The current MOC added mandatory HARP referrals, and a HF HELP Line, giving patients, carers, and GPs direct access to the HF clinic. Monitoring of process measures, as part of the SCV HF Collaborative, was undertaken between March 2022 and December 2022. A new HF model of care has been implemented. Over 10 months, 70% of the 185 inpatients seen received all five steps. New HF CR services are now operating. Challenges that were encountered included the paper-based medical records system, and worsening GP access (step 4), which was unsurmountable. Readmission and process data are being monitored in order to evaluate the HF MOC impact on readmissions, length of stay, and quality of life measures.