Chronic Heart Failure

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

Clients referred to the Chronic Heart Failure stream are seen by a multidisciplinary team.  Chronic Heart Failure aims to support the GP to manage their client in the community.  Clients are referred either from hospital (after an inpatient episode), from General Practice or through a private Cardiologist.

Self management education is provided by Clinical Nurse Consultants.  Education about the early warning signs and symptoms of fluid retention, when to seek appropriate early treatment by the GP and what to do to minimise exacerbations is provided.  Some clients, in consultation with their cardiologist, are taught to self-dose with Lasix if required.  This program recognises hospital admissions are a necessary part of the chronic illness.  The aim is to prevent unnecessary admissions to hospital.

Heart failure clinic review: These visits are an initial assessment within a month of discharge and follow up visits at 3 and 12 months.  The purpose is to support the GP in the care of the patient.  Recommendations are made and sent to the GP in a timely manner.  Ongoing follow up is done by phone or home visit to encourage the client in self-management and compliance with therapy for their heart failure.

Psychological assessment: Clients are screened for depression and referred to the Program’s Psychologist as needed.

Medication review and monitoring: Our pharmacist will monitor the client’s adherence with medication as well as answer any queries about their medication.  If compliance issues are identified our Pharmacist will visit the patient in their home and work with the patient and carers to ensure medication is being taken as prescribed.

Exercise Program: Physiotherapists develop and monitor home-based exercise activities and client responses to exercise programs.

Chronic Heart Failure Rehabilitation Program: This is a 10 week, stage two Heart Failure specific cardiac rehabilitation program.  It is facilitated by the CHF Physiotherapist and conducted at Casey and Dandenong Hospitals.

Exercise Maintenance Program: This is facilitated by an Exercise Physiologist in Fitness Centres.  A ten week exercise maintenance program will be offered to suitable clients.  Clients are encouraged to continue utilising community exercise resources and a home exercise regime.

Eligibility

  • 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

Cost

  • 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.

Referral

Once the referral is received an initial assessment is done to check suitability.  Clients are then contacted to get consent if they are eligible and a Care Co-ordinator is allocated or an appointment is given.

Any clinician can refer patients to the service.  Chronic Heart Failure works with adults and can provide support to patients for up to one year.

Contact Details

Monday – Friday 8:00am – 4:30pm