Heart to Heart: Partnership to improve outcomes for Chronic Heart Failure Patients in Western Sydney

Introduction: Chronic Heart Failure (CHF) is a complex and disabling disease with increasing prevalence in Australia, affecting 10% of people over the age of 65 and estimated cost of $1 billion per annum. CHF hospitalisations are potentially preventable when patients have timely access to healthcare services; receive evidence based, co-ordinated care across the continuum of primary, secondary and tertiary services. Background: Data analysis at Blacktown and Mount Druitt Hospital (BMDH) Western Sydney Local Health District (WSLHD), identified 84% of 2012/13 CHF admissions were Potentially Preventable Admissions (PPA), including 28 day re-admission rate of 28%. A team was established in February 2014 with the goal to reduce PPA from 84% to 70% by October 2015, developing strategies to support patients to live well at home, improve their health outcomes and experience of care over the lifetime of their disease. Methodology: The New South Wales Agency for Clinical Innovation (ACI) Healthcare Redesign Methodology was utilised. Five phases including initiation, diagnostics, solution design, implementation and evaluation; the methodology emphasises partnership with patients and stakeholders. Over 5 months, 35 stakeholders including patients and staff from BMDH, Community, General Practice and Medicare Locals participated in workshops, interviews, forums and data collection. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116642– http://www.ijic.org/