Multidisciplinary and integrated heart failure care at the São Francisco Xavier Hospital in Lisbon

The São Francisco Xavier Hospital in Lisbon has developed a multidisciplinary heart failure management programme ensuring integration of care across settings.¹ Under the programme, care is delivered across three levels: an acute heart failure unit for urgent care integrated in the Internal Medicine Service; a heart failure outpatient clinic for ongoing and critical care whenever necessary; and an advanced consultation for people at lower risk of exacerbation.^{1 2} In addition, the hospital has agreed referral protocols with specialist centres providing invasive cardiac treatment.³

Care is delivered by a truly multidisciplinary team, including cardiologists, internists, nephrologists (kidney specialists), nurses, pharmacists, physiotherapists and allied health professionals.¹ The outpatient clinic is coordinated by specialist nurses under supervision by a physician specialising in heart failure. People with heart failure are seen here 7­–14 days after discharge to adjust medications if required. Care provided at the outpatient clinic places significant emphasis on patient education and empowerment.

This care model recognises the value of close involvement of GPs in the management of heart failure. The hospital team sends them the discharge summary, and GPs have use of a referral system with immediate access to the outpatient heart failure clinic and the advanced consultation within two weeks, depending on the patient’s needs.⁴

References

1. Fonseca C. 2018. A Heart Failure Clinic. European Heart Journal 39(10): 826-8
2. Campos L. 2020. Interview with Sara C Marques at The Health Policy Partnership (Secretariat for Heart Failure Policy Network) [videoconference]. 11/09/20
3. Fonseca C. 2020. Interview with Sara C Marques at The Health Policy Partnership (Secretariat for Heart Failure Policy Network) [telephone]. 08/09/20
4. The Heart Failure Policy Network, Campos L, Herdeiro V, et al. 2020. Strategic consensus for heart failure in Portugal. Lisbon: Catholic University of Portugal