At the heart of home-based care: multidisciplinary heart failure management in a quaternary centre's community programmes.
Nearly all home-based heart failure patients received education, but therapy optimization was rare.
At the heart of home-based care: multidisciplinary heart failure management in a quaternary centre's community programmes.
Heart failure (heart failure) is a frequent cause of hospital admissions, carrying a high risk of hospital readmission and mortality.
To characterise delivery of care to patients with heart failure within Alfred Health General Medicine Hospital in the Home and Hospital Admission Risk Program across four domains: symptom management, patient education and self-management, optimisation of guideline-directed medical therapy (guideline-directed medical therapy) and values-based discussions regarding disease trajectory and advance care planning.
A single-centre retrospective cohort study was conducted on every second heart failure patient discharged from Hospital Admission Risk Program between 1 July to 31 August 2024.
Mean age was 82 years and mean Charleson Comorbidity Index score was 6.
Heart failure was a new diagnosis for 23%, and ejection fraction was preserved in 46%.
Eighty-eight per cent were hospitalised in the preceding 12 months, and 67% required in-home assistance.
There was no uniform approach to symptom monitoring.
Community-based heart failure care consistently delivered heart failure education and occasionally considered guideline-directed medical therapy optimisation.
This older, multimorbid patient cohort would likely benefit from greater opportunity for shared decision making and early introduction of palliative care services.