Head: Dr Peter Bergin [Bio]

The Heart Failure/Heart Transplant Service is the only programme in Victoria offering all modalities required for heart failure care from diagnosis through to mechanical circulatory support and transplantation. It is included as part of core training for Advanced Trainees in Cardiology and also provides a 12 month Fellowship for those pursuing a career in Heart Failure or Cardiac Transplantation.  The programme offers a multidisciplinary approach to care including nurse co-ordinators, allied health and cardiac rehabilitation programmes.

Our team is actively involved in research into the mechanisms that underpin the progressive nature of heart failure, the development of new treatments and the evaluation of new biochemical and imaging modalities to predict heart failure progression.

The programme is fully integrated into the mainstream Cardiology Department and offers great opportunity for collaborative work not only within Cardiology but areas such as Imaging and Exercise physiology.

The Heart Failure Outpatient programme is designed for adult patients whose major problem is Heart Failure, either systolic or diastolic.  Patients should have no major contraindications to receiving advanced heart failure options which may include device therapy, mechanical support and transplantation.

Book: Your Guide to Heart Failure

Model of Care for Heart Failure Patients

Alfred Health has launched a new health service wide model of care for patients admitted with heart failure in February 2017.  An extensive consultation process with multi-disciplinary clinicians and patients was undertaken, and in-depth analysis of data sources including the VCOR Heart Failure Snapshot and Victorian Admitted Episodes Dataset to understand the patient journey.

The aim of this model of care (see figure below) is to maximise the time heart failure patients spend well in the community by delivering best practice guidelines to reduce variation in care improving overall outcomes.  This will ensure that patients admitted with heart failure under general cardiology, heart transplant and general medicine units get the best care appropriate for their needs.

A heart failure care bundle is started on admission by the medical team, which is a checklist of evidence based interventions shown to improve outcomes for heart failure patients.  These include cardiac assessment, heart failure medications, multi-disciplinary care, heart failure patient education pack including simple guide to self-care, a weight chart and the Heart Foundation heart failure action plan.  The bundle also delivers transitional support through early referral to cardiac rehabilitation, and a phone call at home by 72 hours with home visits from the Hospital Admissions Risk Program if required.  Patients with heart failure will be followed up early in their admitting unit’s outpatient clinics, and a heart failure early follow up clinic run by a heart failure nurse and pharmacist has been established to service General Cardiology patients.  A heart failure nurse is available across the hospital during office hours to support the program.

alfred health heart failure model of care

As well as providing consistent evidence based care across the hospital, this model using heart failure care bundles allows the provision of near real-time feedback to clinicians about the quality of care provided at Alfred Health, driving quality improvement. In this way we will ensure that all heart failure patients receive the best care.

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Consultation in the Heart Centre is only by referral from a Medical Practitioner.

I am a HEALTH PROFESSIONAL

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