Northern Health’s Hospital Admission Risk Program (HARP) is lending a helping heart to heart failure patients.

Heart failure is a complex chronic condition, with one in four patients with heart failure readmitted to hospital within 30 days of being discharged. To help heart failure patients after a hospital admission, Safer Care Victoria (SCV) has partnered with HARP to co-design and test a service delivery model called Heart Helper.

“There is an increased need for patients and families to acquire disease self-care skills to successfully manage their condition outside of hospital due to shorter hospital stays,” said Oksana Kasapis, Project Lead.

“The Heart Helper project is designed to increase patient self-care and management and improve patients’ as well as carers’ health knowledge of heart failure.”

“In addition, the aim of the project is to provide non-therapeutic intervention (psychological support) that helps a person cope with stressors of heart failure diagnoses in the home, and refer where needed, to psychology services.”

“By improving patient knowledge about when to seek help and what help is available, our aim is to minimise the risk of heart failure related hospital readmissions.”

‘Heart helpers’ have the capacity to see heart failure clients face-to-face after hospital discharge more frequently in the comfort of their home. They not only monitor client medication, dietary restrictions and weight management adherence, but also try to reduce the burden of the disease by making it more fun – do gardening, cooking and even puzzles together.

“To strengthen our community relationship, we also include our consumers in many steps of project implementation and updates,” Oksana said.

“The project involves trialling a combined workforce model that is supportive and effective, and for the first time, we have the opportunity to have both Division 1 and 2 nurses working in HARP.”

Safer Care Victoria representative Simone Rafferty recently visited the Heart Helper team to experience how the new model of care is progressing.

“The Northern Health Heart Helper team is doing an excellent job in trialling this client-centred approach, using an alternative skill mix with complex patients,” Simone said.

“To engage heart failure patients with self-care, the team is using outside-of-the-box methods, making it more human-centred.”

“Having an occupational therapy background myself, I know well enough that as much as we would like to spend time with our patients, very often this is not the case. I am glad that Northern Health Heart Helpers, Division 2 Nurses Mustafa Tus and Margaret Toohey are doing exactly that – they have time to really listen to what our clients have to say.”

Mustafa said some of their patients had lifelong habits that are hard to change, and it takes time to incorporate new habits, like recording their weight each day, as part of the program.

“We can spend that time, using teach-back, and encouraging them when they progress,” Mustafa said.

The Heart Helper Pilot project has been granted additional funding to continue to develop and evaluate this new model of care and was recently announced as a finalist in the Victorian Premier’s Design Awards for the service design category in 2022.

Visit the Intranet for more information about HARP.

Featured image: Oksana Kasapis, Margaret Toohey and Mustafa Tus