The Chronic Heart Failure (CHF) program works in partnership with GPs and cardiologists to support their clients within the community.
The program aims to prevent hospital admissions and improve quality of life through self-management education and support delivered by clinical nurse consultants and nurse practitioners. Education topics include CHF management, signs and symptoms of fluid retention, when to seek treatment, and how to minimise exacerbations. Clients are supported short-term and then discharged to a GP and/or private cardiologist.
Services include:
- Self-management education
- Diuretic titration
- Heart Failure clinical review
- Psychosocial needs assessments and referral to allied health or psychologist as appropriate
- Medication optimisation
- Medication review, understanding and adherence, and where appropriate a referral to HOMR is completed
Eligibility Criteria
This service is for clients who:
- are over 18 years old and reside in the Monash Health catchment.
- have a Chronic Heart Failure diagnosis
- have had a presentation to ED or hospital admission with LVF, APO or associated symptoms of Chronic Heart Failure
- have an echocardiogram indicating heart failure
- are at high risk of presenting with exacerbation of symptoms of Chronic Heart Failure
This service is not for clients:
- whose primary condition is Hypertrophic Obstructive Cardiomyopathy (HOCM), Amyloidosis or Sarcoidosis
- whose primary condition is renal failure on dialysis, eGFR<15%
- whose primary condition is mental health, alcohol or drug dependence
- whose primary condition is cancer
- who are receiving palliative care
- who are pregnant or post-partum
Referral Method(s)
Clients can be referred by:
- clinical staff
- cardiologists
- GPs
- self
Referrals should be sent by eReferral through Healthlink or by email.
Phone:  03 8572 5631
Email:  icareaccess@monashhealth.org
Eligible Postcodes
- Cardinia:3781, 3782, 3783, 3807, 3808, 3809, 3810, 3812, 3813, 3814, 3815, 3981, 3981, 3984
- Casey: 3177, 3802, 3803, 3804, 3805, 3806, 3807, 3912, 3975, 3976, 3977, 3978, 3980, 3981
- Kingston: 3169, 3189, 3189, 3190, 3192, 3194, 3195, 3196, 3197, 3202
- Greater Dandenong: 3164, 3171, 3172, 3173, 3174, 3175, 3975
- Monash: 3125, 3147, 3148, 3149, 3150, 3164, 3166, 3167, 3168, 3170, 3800
Additional information required
Include all patient demographic and clinical details as well as relevant investigation results
Contact hours: 8.30am – 4.30pm, Monday to Friday (except public holidays)
Click here for more information about this service.
Please review the eligibility criteria before submitting a referral.