Optimising Transitional Care Following a Heart Failure Hospitalisation in Australia

Andrew P Sindone; Andrea Driscoll; Ralph Audehm; Aaron L Sverdlov; James McVeigh; Wai Ping Alicia Chan; Annabel Hickey; Ingrid Hopper; Tim Chang; Andrew Maiorana; John J Atherton

doi:10.1016/j.hlc.2023.11.029

Optimising Transitional Care Following a Heart Failure Hospitalisation in Australia

Heart Lung Circ. 2024 Apr 30:S1443-9506(24)00193-8. doi: 10.1016/j.hlc.2023.11.029. Online ahead of print.

Authors

Affiliations

¹ Heart Failure Unit and Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia. Electronic address: andrewsindone@bigpond.com.
² Department of Cardiology, Austin Health, Melbourne, Vic, Australia; School of Nursing and Midwifery, Centre for Quality and Patient Safety, Faculty of Health, Deakin University, Geelong, Vic, Australia.
³ Department of General Practice and Primary Health Care, The University of Melbourne, Melbourne, Vic, Australia.
⁴ School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia.
⁵ Heart Failure Service, The Prince of Wales Hospital, Randwick, NSW, Australia.
⁶ The Queen Elizabeth Hospital, Adelaide, SA, Australia.
⁷ The Prince Charles Hospital, Brisbane, Qld, Australia.
⁸ School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology and General Medicine Unit, Alfred Health, Melbourne, Vic, Australia.
⁹ Fiona Stanley Hospital, Perth, WA, Australia.
¹⁰ School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia; Allied Health Department and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Perth, WA, Australia.
¹¹ Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia; Faculty of Science, Health, Education and Engineering, University of Sunshine Coast, Sunshine Coast, Qld, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Qld, Australia.

PMID: 38692982
DOI: 10.1016/j.hlc.2023.11.029

Abstract

Hospitalisations for heart failure (HF) are associated with high rates of readmission and death, the most vulnerable period being within the first few weeks post-hospital discharge. Effective transition of care from hospital to community settings for patients with HF can help reduce readmission and mortality over the vulnerable period, and improve long-term outcomes for patients, their family or carers, and the healthcare system. Planning and communication underpin a seamless transition of care, by ensuring that the changes to patients' management initiated in hospital continue to be implemented following discharge and in the long term. This evidence-based guide, developed by a multidisciplinary group of Australian experts in HF, discusses best practice for achieving appropriate and effective transition of patients hospitalised with HF to community care in the Australian setting. It provides guidance on key factors to address before and after hospital discharge, as well as practical tools that can be used to facilitate a smooth transition of care.

Keywords: Heart failure; Hospital discharge; Hospitalisation; Multidisciplinary management; Transition of care.