HFpEF: continuity of care and multidisciplinary collaboration across healthcare settings

The São Francisco Xavier Hospital in Portugal has implemented a multidisciplinary heart failure (HF) management programme that welcomes all people living with HF regardless of their left ventricular ejection fraction.

The programme relies on a multidisciplinary team working across an acute HF unit, an HF outpatient clinic and an advanced HF consultation. Patients are discharged only after complete stabilisation and referred to an appointment at the outpatient clinic in 7–14 days. Discharge summaries are sent to each person’s GP.

The programme includes an agile referral system between primary care centres and both the acute unit and the outpatient clinic, so that GPs can send people in need of urgent care directly to the acute unit, and those in need of non-urgent HF consultations to the outpatient clinic. The outpatient clinic is led by nurses, and at the centre of care is the provision of education to the person with HF and their carer(s). The clinic helps avoid hospital admission by supporting people in early stages of HF exacerbation.

References

Fonseca C. 2018. A Heart Failure Clinic. Eur Heart J 39(10): 826-28