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. Rationale for change
Heart Failure is a health condition that embodies the full spectrum of challenge in achieving effective integrated care:
Complex medication regimes require careful management by Heart Failure Nurse, GPs and Specialists
a high degree of enablement and understanding on the part of the consumer/carer (self- management and education)
a decline in health can require in-patient stays with associated transfer of care into and out of the hospital
and as the disease progresses, the need for palliative care in the community and/or in a hospice setting can arise
Inconsistent and fragmented care and management for Heart Failure across different sectors in the ACT (private and public/acute and primary)
High/frequent hospital admission and readmission, escalating health care costs on acute services

3. Overarching aims and objectives
The main objective is to develop and implement a whole of system approach to the management of Heart Failure that involves evidence- based, multi-disciplinary and patient-centred care.
Implementation of a co-designed integrated HF model of care into service delivery to improve patient outcomes, consumer experience and optimise community based workforce capacity

4. Diagnosis Results – Project Integrate Framework
Highlighted the key issues that were all raised during the HF model of care co-design process:
Lack of care coordination between HF nurses, GPs and specialists around the patient’s needs
Poor discharge planning (quality of discharge referrals) and communication between the care team
Unclear roles and responsibilities of the care team to ensure patient centred, seamless team based care (integrated care)
Limited education around self management strategies and supported self-care
The co-designed Heart Failure Model of Care is underpinned by the principles of integrated care

5. Analysis and design results – program logic
OUTCOMES
INPUTS
OUTPUTS/ACTIVITIES
Short Term
Longer Term
Remodel referral pathway for HF nurse and ECHO
HF nurse
Improved timely diagnosis of HF
Multi-disciplinary coordinated and comprehensive care is delivered across hospital and community setting, driven by their goals of care
Establish a HF HUB
Clear roles and responsibilities guideline of the care team (incl pall care)
Protocols/cycle of care
MDT Team
Improved sharing of clinical information across care settings
Cardiologists (public/private)
Reduced length of hospital stay
Develop a community based HF service (HF nurse/care coordinator) -
Care coordination and enhanced management for HF patients in the community
Reduced potentially preventable hospitalisations
GPs/Practice nurse
Optimised health outcomes and improved quality of life
Consumers/carers
Develop patient-led management plan and action plan
Patients utilise/understand management and action plans
Funding
Develop tailored tools and resources to enable HF self management
Use of the patient activation measure to determine pts activation level and tailored self management strategies
Increased safe self management for HF patients
Partners (ACT Health, Heart Foundation & Healthcare Consumers)
Tailored CPD training and education for GPs and PN on symptom, treatment, titration, self management education and action/care plans
Increase in knowledge and confidence & skill to manage HF patients in general practice setting
Optimise GP and general practice capability

6. Mission Statement
To provide patient centred, coordinated heart failure care, through the implementation of an integrated heart failure model of care (co- designed by clinicians and consumers) for the ACT

7. Action plan with timescales
3 Months:
Project partners - re-evaluate key priority areas for implementation and what is achievable (timeframes), commitment of vision and investment
Re-engage with HF Clinical Leadership Forum and consumers – celebrate achievements
Identify local champions – focusing on GPs and Practice nurses
Identify additional strategic key partners (e.g. NGO’s, peer support groups)
Review co-designed outcomes framework, which established a common indicator set to determine whether HF patient shave been provided with best practice multi-disciplinary treatment and support – inclusion of patient reported outcomes and experience
Progress the development of tools and resources identified in the program logic to achieve quick wins – continued co-design approach
Develop a change management/adoption strategy with project partners and Clinical Leadership forum to drive the implementation
3-6 months:
Phased implementation of priority key areas (July 2018)
Ongoing communication and engagement with HF Clinical Leadership Forum, identified local champions – communication strategy
Determining what data is currently collected in both community ad hospital based setting
Formative evaluation partners – monitor implementation/data collection - how we can apply the co-designed outcomes framework
6-9 months:
Phased Implementation, adaptive learning process to monitor change effectiveness
Continued engagement with the HF Clinical Leadership Forum, local champions, key stakeholders, project partners