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“Heartlink” Collaborative Care for CHF

“Heartlink” Collaborative Care for CHF. James P McVeigh Nurse Practitioner. Area. Demographics. Disorder of the elderly Most common single cause of hospital admission > 75 yrs. Readmission rates of 30-40% within 6 months Comorbidity common eg CAL, diabetes

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“Heartlink” Collaborative Care for CHF

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  1. “Heartlink”Collaborative Care for CHF James P McVeigh Nurse Practitioner

  2. Area "Heartlink" Collaborative Care for CHF

  3. Demographics • Disorder of the elderly • Most common single cause of hospital admission > 75 yrs. • Readmission rates of 30-40% within 6 months • Comorbidity common eg CAL, diabetes • Projected large increases in population of patients with CHF "Heartlink" Collaborative Care for CHF

  4. Chronic Care • Developed from NSW Health chronic care initiative • Nurse led multidisciplinary approach, principally home based interventions • Collaborative approach to care "Heartlink" Collaborative Care for CHF

  5. Conventional Approach to CHF • Underutilization of proven drug therapy • Patient non compliance • No flexible diuretic regimes • Failure to emphasize non pharmacological management • Failure to attend to problems in the elderly • comorbidity • polypharmacy • inadequate social support • depression • cognitive deficit "Heartlink" Collaborative Care for CHF

  6. Service Objectives • Promote seamless transition of care between the hospital and community • Improve the quality of life of people with chronic and complex health care needs • Improve the quality of life of their carers and families • Prevent crisis situations and urgent admissions to hospitals "Heartlink" Collaborative Care for CHF

  7. Principal Components of Service • Optimization of medical therapy • promoting best clinical management in accordance with the NHFA guidelines • Community follow up providing home based education, assessment and support • Improved access to health care providers • Increased access to physical activity programs • Palliative and end of life care "Heartlink" Collaborative Care for CHF

  8. GP Collaboration Optimising medication management in accordance with NHFA clinical guidelines • Assistance to promote compliance and facilitate access to Cardiologist • Assistance in initiation and up titration of Carvedilol • Collaboration on activation of Emergency Medical Action plan "Heartlink" Collaborative Care for CHF

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