1. Heart Failure Care Initiative- whole of system approach to Heart Failure care in the ACT
International Summer School on Integrated Care
Daniela Gagliardi
Heart Failure Care Initiative – Project Manager
Capital Health Network (ACT PHN)
Marg McManus
CNC, Cardiology, Rehabilitation and Outpatients, Cardiology, The Canberra Hospital

2. Heart Failure in A.C.T
Despite advances in heart failure management clinical outcomes remain poor
Considered one of the most frequent potentially avoidable Emergency Department (ED) (re)presentations and hospital (re)admissions and is associated with escalating health care costs
Emphasis on hospital based care creates an unsustainable burden on specialist and acute services.
Alternative models that involve community based, multidisciplinary general practice setting are gaining prominence.
Agenda for the meeting
Ref: Chen L, Booley S, Keates AK, Stewart S.  Snapshot of heart failure in Australia.  May 2017.  Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia

3. Heart Failure Care Initiative
The main objective is to develop and implement a comprehensive and systematic approach to the management of Heart Failure that involves evidence-based,
multi-disciplinary and patient-centred care.
Phase 1: Establishing Heart Failure Clinical Leadership Forum
Phase 2: Development and co-design an integrated Heart Failure Model of Care
Phase 3: Implementation and system reform - phased implementation from July 2018
Agenda for the meeting
The challenge is now the translation of the Heart Failure integrated care model into service delivery

4. Heart Failure Care Initiative – implementation
Priorities for action were identified and implementation plan established, encompassing two streams of developmental activity
Short to medium term strategies for implementation of the Heart Failure integrated model of care have been identified:
The Establishment of a Heart Failure Hub – coordinating structure providing a more comprehensive shared care/team-based approach for patients with heart failure across three key areas – management, education and rapid assessment
Community-based Heart Failure nurses- comprehensive and continuous care across the patient journey encompassing goal setting and multidisciplinary care planning.
Consumer enablement, self-management and peer supports -tailored heart failure related self-management interventions, tools and resources
Multi-disciplinary and whole of system workforce development - establish a comprehensive multidisciplinary CPD program to support the implementation of the Heart Failure Model of Care
Agenda for the meeting
Implementation of interventions will involve the need for changes in roles and formal and informal power structures including both public and private cardiology

5. Key issues to explore Learning more on how we can:
Change the current culture and power structures
Support local champions and clinical leads – while operating within limited resources
Develop targeted and effective change/adoption and integration strategies
Ensure sustainability and establish key partnerships
Agenda for the meeting

6. Thank you!