Chronic Heart Failure

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.



Monday to Friday from 8:00am – 4:30pm


There is no cost for the Chronic Heart Failure program, clinic or rehabilitation. The Exercise Maintenance Program charges a small fee for use of the Fitness Centre.

Eligibility criteria

  • Diagnosis of Chronic Heart Failure
  • Recent presentation or admission with LVF, APO or associated symptoms of Chronic Heart Failure
  • Echocardiogram indicating heart failure
  • Client is at high risk of presenting with exacerbation of symptoms of Chronic Heart Failure
  • Medicare Card holder

Referral details

SACS Access and Intake

Phone:  (03) 8572 5631

The journey of people with heart failure

Heart failure (HF) is associated with a high mortality and morbidity, reduced quality of life and increasing health care costs in Australia as well as across the world. The projected crude prevalence of HF is expected to increase significantly as the population ages.  People >65 years of age have a higher prevalence of all cardiovascular disease, and this population will grow significantly in the next two decades.

The rising trend in mortality and hospital admissions is likely to continue as the aging population grows. HF prognosis remains poor, often due to late diagnosis and inadequate management and support. 20-30% of people with mild to moderate heart failure will die within one year and 50% of people with severe heart failure will die within one year.

There is an expected 25% growth in prevalence of HF by 2030 compared to 2010; and to a doubling of the direct medical costs associated with HF. Within this context, HF constitutes a public health problem that has been characterised as an emerging epidemic by the World Health Organisation.

To understand the journey a person who has heart failure a study on the current state at Monash Health has been undertaken.

In addition over three years Monash Health Hospital Admission Risk Program has led a large scale systems reform for Heart Failure care. The system redesign has had a focus on responsiveness and demonstrating excellence in care delivery. Most significantly is the Complex Care response which links inpatient and ED patients with specialty community based Nurse Practitioner and Clinical Nurse Consultant care and support. This service has a focus on (where appropriate) early discharge and community follow up this includes Lasix titration in community and linkages with G.P. for continuity of care. The following system monitoring and controls have been put in place
– Clinical risk screening discharged patients within 2/7days
– Clinical indicators to measure service delivery of best practice
– Peer audits of translating evidence to practice
– Protocol for deteriorating clients in community
– Feedback from patients in Appendix A clearly demonstrates people value this service delivery model