Outpatient Management of Patients with Heart Failure

Planning for Heart Failure (HF) management must develop the capacity to care for an aging cardiac population. Older HF patients often require regular follow up with close monitoring for potential complications and worsening symptoms that may contribute to acute care utilization. Although HF disease management programs are beneficial, the growing population of older HF patients and the limited availability of specialized HF clinics call for system level interventions to optimize care and clinical outcomes. The purpose of this paper is to propose an integrated, patient centered system to manage HF. Patient management should be firmly rooted in the primary care sector that is highly integrated with specialty services and be based on a chronic disease management framework. Patients are stratified according to clinical risk and complexity with the intensity of intervention adjusted accordingly. Care is organized within a ‘Hub and Spoke’ Model, whereby the patients move between the levels of care as guided by their risk stratification. This integrated model of care will also help establish close working relationships among care providers who may be currently operating in isolation, and thus foster opportunities for greater knowledge translation and exchange and capacity development.