Person-centered integrated approach in an advanced heart failure clinic

E-mail: ks@menteebenessere.it Goal: Cardiovascular disease (CVD) constitutes epidemiological, clinical and social emergency and requires an effective and efficient person and people-centered integrated interventions to empower patients, increase adherence and improve clinical-psycho-social outcome. This interdisciplinary, integrated approach requires holistically attending to the person's needs both through the supportive and the palliative stages of heart failure. Material and Methods: In 2013, an Advanced Heart Failure Clinic (AHFC) was activated within the Outpatient Cardiovascular Department in Trieste. AHFC is made up of an interdisciplinary team (2 cardiologists, an internist, a psychologist, and 4 dedicated nurses) who collaborate with GPs and healthcare professionals from the four District teams which make up the Province of Trieste. The goal is to provide person-centered, integrated supportive and palliative care to patients with an advanced heart failure (NYHA III-IV) after the discharge from hospital/residential facility, or to those requiring longitudinal monitoring (both as outpatients or at their homes). A Person-Centered Psycho-Social Wellbeing Questionnaire (PCPSWQ) was developed to investigate personal, social and healthcare well-being as well as the knowledge of the disease and the level of adherence. HEART FAILURE Proπireni saaeetak / Extended abstract