October 1, 2019

Huge success of our Heart Failure program

Patients who are diagnosed with heart failure in the northern suburbs will now be better managed in participating GP clinics thanks to Northern Health’s unique ‘Heart Failure in the North’ education program, which provides personal education and upskilling for GPs and primary care nurses.

The program started in March 2016 by recruiting four large GP clinics that were geographically located near Northern Health and whose patients were regularly presenting to hospital for heart failure.

Associate Professor Gautam Vaddadi, head of the program explained that a lot of patients with heart failure are not treated with the most appropriate evidence based care, particularly the use of complex combination medications. GPs frequently find this a challenging area to practice in, and with evidence changing rapidly, GPs need more support from specialist hospital services to ensure patients are maintained on evidence based treatment. He and his team sought to improve that standard and build a link between the hospital and general practice.

“There is a strong recognition that heart failure patients are being sub-optimally managed and a lot of that care is controlled in the community. After speaking with A/Prof Ralph Audehm GP, who has done a lot of work in the diabetes space, we decided that heart failure would be a good condition to engage with primary care on and build a skill base within general practice to manage heart failure,” he explained.

Fiona Miller, Heart Failure nurse who runs the education sessions added that during the second year of the program, the team recruited two more clinics, so six clinics in total were engaged in education during the first two year period. Currently, she is working with 30 medical clinics in the northern region of Melbourne.

“The goal of the project was to improve evidence based medication use in heart failure patients and we looked at ways to make that happen. While collecting data from GPs on these patients, we recognised that there was a gap in the way these patients were coded. They were all given a generic diagnosis – Congested Cardiac Failure (CCF). That code doesn’t really tell the GPs what kind of heart failure the patient has, and for the patients to be managed correctly, the GPs needed to know what type of heart failure it is,” Fiona explained.

She further explained that once that cohort of patients was classified correctly, she did a lot of education around diagnostics for the type of heart failure, especially with the nurses who were engaging with patients around their “care plan”.

“I worked very closely with the nurses in the medical clinics, around management of chronic heart failure to help nurses better understand how to educate and support patient management. I would sit in the room with the nurses and initially do all the education with the patient during care planning. This process of the nurse learning by example helped link the theory to practice. Nurses then felt more confident to discuss heart failure self-management with patients and over time it became standard care,” she explained.

“We used the GPMP (GP management plan) to identify gaps in management and alert the GP,” she added.

The nurses valued the practical aspect of the education program. The feedback from patients was fantastic and they ‘felt looked after and felt better at home.’

Fiona and Gautam agree there is a big difference between this program and education programs from other hospitals. With this program, Fiona is able to link in with the patient at the hospital and use that to connect with the GP who is looking after the patient. In essence the patient becomes the “vector” for education and system improvement between the hospital and primary care. Traditionally there has been a wall that separates the hospital system from the GP system.

“We are breaking those barriers between general practice and hospitals,” A/Prof Vaddadi explained.

The response from the GPs has been fantastic, and Fiona has been receiving numerous letters of support, appreciation and encouragement.