August 23, 2022The Northern Health Cardiology Heart Failure team is aiming to improve outcomes by empowering patients to self-manage their condition, with appropriate clinical support.
The Cardiovascular Ambassador Project involves 20 participating health services and hospitals, including Northern Health, and aims to improve the quality of cardiac care delivered to patients and reduce unplanned hospital readmissions.
Participating hospitals have received funding for a cardiovascular liaison nurse to plan, lead, implement and coordinate appropriate multifaceted interventions for each site’s model of care.
Heart failure self-management has been regarded as a central part of heart failure care. Self-management is the central pillar that allows patients to be managed in the community, with the support of their general practitioner.
Patients who are admitted to hospital with decompensated heart failure have an opportunity to become “activated” participants in their own management while they are in hospital.
Project Lead and Head of Heart Failure Services, Associate Professor Gautam Vaddadi, proposed a new model of care, with patients directly involved in fluid intake and weight documentation, medication management, and self-assessment of fluid status while in hospital, and in the Hearts at Home virtual ward.
“Traditionally, patients are passive recipients of care – nurses deliver care, patients receive one hour of education about self-management as per standard practice and are discharged. This is even worse for those with poor health literacy, diverse cultural backgrounds and those who are non-English speaking. This group of patients are a very large proportion of the Northern heart failure case-mix, and require additional targeted support,” Gautam said.
Madonna Goro, Northern Health Cardiac Liaison Nurse, said, “Readmissions incur significant costs, and demand challenges for healthcare services. Targeted activity to improve inpatient cardiac care, discharge processes, follow up and communication across care settings have been successful in reducing readmissions.”
“By June 2023, we aim to increase patient and carer confidence, and knowledge of self-management practices for health failure patients. We also aim to increase nurse confidence and knowledge to provide education to heart failure patients, and support them in self-management practices, whilst admitted as an inpatient.”
Madonna expressed the joy of being able to go on the journey with these patients, to empower and equip them with the appropriate tools to self-manage their heart failure condition.
“Understanding where the patient is at and what matters to them is so important in the education process. We help them understand that we are here to support them in their health journey, and bring a sense of hope that what they are going through can be well managed,” she said.
“We also want to improve the transition from the acute sector into the community by increasing referrals to relevant services such as heart failure rehabilitation, Hospital at Risk Program (HARP), and Hearts at Home virtual ward for eligible patients.”
As the Cardiac Liaison Nurse, Madonna is educating patients on heart failure self-management strategies, and is offering support to patients to practice these strategies whilst in hospital. She is also providing patients and carers with resources in their own language.
“I then follow them up with a phone call at 30 days and 90 days to evaluate whether the interventions result in sustained use of self-care strategies and to see if they require further advice or support,” Madonna said.
“We chose these time points as we found these were the vulnerable periods for heart failure readmissions. We hope by intervening here, this could prevent a readmission,” Gautam said.
The project is also helping to upskill nurses to reiterate education and heart failure action plans to patients through their everyday practice.
“We hope that, by nurses being well-equipped in supporting heart failure patients, and heart failure patients empowered and connected to the right services at discharge, that readmission rates reduce,” Madonna said.
Featured image: Associate Professor Gautam Vaddadi, and Madonna Goro.
