At the heart of home‐based care: multidisciplinary heart failure management in a quaternary centre's community programmes

BACKGROUND: Heart failure (HF) is a frequent cause of hospital admissions, carrying a high risk of hospital readmission and mortality. Alfred Health General Medicine Hospital in the Home (GM-HITH) and Hospital Admission Risk Program (HARP) offer multidisciplinary HF care to multimorbid patients in bed-substitution and non-admitted community care models. AIMS: To characterise delivery of care to patients with HF within Alfred Health GM-HITH and HARP across four domains: symptom management, patient education and self-management, optimisation of guideline-directed medical therapy (GDMT) and values-based discussions regarding disease trajectory and advance care planning. METHODS: A single-centre retrospective cohort study was conducted on every second HF patient discharged from HARP between 1 July to 31 August 2024. Data were collected from electronic medical records, and summary statistics were provided. RESULTS: Forty-eight patients were included. Mean age was 82 years and mean Charleson Comorbidity Index score was 6. HF was a new diagnosis for 23%, and ejection fraction was preserved in 46%. Eighty-eight per cent were hospitalised in the preceding 12 months, and 67% required in-home assistance. HF education was provided to 98% of patients. There was no uniform approach to symptom monitoring. Patients were infrequently considered for GDMT optimisation. Six patients were deceased at the time of data collection, typically without documented discussion about HF prognosis or advance care planning. CONCLUSIONS: Community-based HF care consistently delivered HF education and occasionally considered GDMT optimisation. This older, multimorbid patient cohort would likely benefit from greater opportunity for shared decision making and early introduction of palliative care services.