Chronic Heart Failure management program

Background

Chronic Heart Failure (CHF) is one of the most remarkable health problems because of its prevalence (up tol 2% in west countries), morbidity and mortality. CHF is a disease of the elderly: approximately 80% of the patients hospitalized with CHF are more than 65 years old. CHF has a strong impact in terms of social and economic effects: very frequent hospital admissions and a significant increase of medical costs.

CHF elderly patients demand an effective and integrated disease management program, because in these patients the following are present: Poor self-care, High prevalence of comorbidities (COPD, diabetes,hypertension, anaemia, renal dysfunction, cancer), High prevalence of diastolic heart failure, Polypharmacy, Physical and cognitive limitations (Difficult transfers to the hospital), Inadequate social support and social isolation, Depression and anxiety, High incidence of precipitating factors, Poor education, Poor compliance to therapy (pharmacological and not), Need of frequent reassessments [1].

Management program [2, 3]

Elderly patients with concomitant diseases (the patient himself and his family are considered as active users)

Personnel Multidisciplinary team providing specialized follow-up: Nurse (responsible for education and follow-up), Specialist (internist, geriatrician, cardiologist), Dietician, psychologist, social assistant.

Primary care physician: Telephone follow-up and improved communication

Methods: Home assistance, improved communication (Easy and frequent telephonic contacts)

Interventions: Patients and family education, Diet counseling, Therapy adjustment, Increase in compliance to diet and therapy, Intensive follow-up for early detection and treatment, Episodes of WHF, Concomitant diseases (e.g. infections).

Aims: Reduction in the incidence of hospitalizations, Improvement in the clinical course / quality of life, Reduction in management costs