Integrating Care: Developing a Primary Care Chronic Heart Failure Disease Management Program - a Tertiary Hospital/General Practice Partnership

Abstract

Background: Patients with chronic heart failure (CHF) require regular assessment, monitoring and self-care support. Clinical care is predominantly delivered by general practitioners (GP), cardiologists, and hospital and community based CHF disease management programs (DMP) which although effective, reach only 20% of patients discharged from hospital. To improve accessibility, there have been calls for the development of primary care based CHF DMP. In support of this proposal, there is evidence to suggest primary care practice nurses (PN) are well placed to contribute to the clinical management of stable chronic disease. Aim: To develop a primary care based CHF DMP through a joint partnership between hospital and general practice clinicians. Method: GPs and PNs from six (6) general practices partnered with tertiary hospital based specialist CHF clinicians over a 12-month period to develop a primary care based CHF DMP. Results: Opportunities and barriers were identified and solutions implemented to inform a primary care based CHF DMP. Barriers included identification of CHF patients, limited resources to support self-care and limited scope of practice and professional support for practice nurses. Opportunities and solutions included standardising disease coding, incorporating an assessment and monitoring template within electronic patient management systems, identifying opportunities to expand the role of the practice nurse, development of self-care support resources and improved communication with hospital based CHF DMPs. Conclusion: Partnerships between hospital and primary care based clinicians can inform the development of a practice nurse supported primary care based CHF CDM to improve clinical management and support care integration.