Supporting improved management of Chronic Heart Failure (CHF) in the community.

The CHF program aims to support the GP to manage their client in the community. Clients diagnosed with CHF are referred from hospital, general practice or private cardiologists.

Successful CHF management involves enrolment in CHF management programs. The goal is to optimise CHF management, prevent hospital admissions and improve quality of life. Self management education is delivered by clinical nurse consultants. Clients are educated about CHF management, signs and symptoms of fluid retention, when to seek treatment and how to minimise exacerbations. This program recognises hospital admissions are a necessary part of the chronic illness. The program supports patients for 12 months, and then discharges them to the GP or private cardiologists.

Heart failure clinic review: Patient can be reviewed at the multidisciplinary CHF clinic over 12 months to ensure medications and treatments are optimised. This facilitates communication between the clinic and GP’s. Recommendations are made and sent to the GP. Ongoing follow up is done by phone or at home visits to support the client in self-management.

Psychological support: Clients can be referred to a CHF specialist psychologist.

Medication review and monitoring: Clients are reviewed by a CHF pharmacist at the clinic or in the home to support adherence and answer questions about the medication regimen.
Chronic Heart Failure Rehabilitation Program: A 10 week, CHF specific cardiac rehabilitation program facilitated by the CHF Physiotherapist at Casey and Dandenong Hospitals.

Exercise Maintenance Program: A supervised ten week exercise maintenance program held in local gyms to encourage ongoing exercise in the community.

**The journey of people with heart failure – using data to understand the care continuum