Opportunities to link Heart Failure Guidelines and chronic disease management-preliminary considerations

Abstract

Background: Enhancing community based Chronic Disease Management (CDM) will make significant impacts on all major chronic disease management outcome measures. There are no successful models of community hubs to triage and manage chronic diseases that significantly reduce readmissions, cost and improve chronic disease knowledge. Chronic heart failure (CHF) management foundations are built on guideline derived medical therapies (GDMT). These consensuses evidenced building blocks have to be interwoven into systems and processes of care which create access, collaboration and coordinate effective and innovative health services.

Methods: Perspective and short communication.

Conclusions: This review explores: (i) conventional chronic disease management in Australia; (ii) Possible options for future chronic diseases models of care that deliver key components of CHF management.

Keywords: chronic disease management; chronic heart failure; clinical guidelines; epidemiology; processes of care; systems of care.

Fig. 1.

Building blocks to navigate patient journeys. Foundations of health systems of care are formulated from a system of care (pyramid). The building blocks of these include disease management systems. interaction of health administrators, formulated knowledge and health services. Health institutions play a critical role in patient journeys via a community health services or acute pathways. A missing component of this pathways a robust, integrated community health hubs that act as a buffer for some cases transitioning between acute and chronic phases. Abbreviations: ACM, acute care model; CCM, chronic care model [7].

Fig. 2.

Template for community chronic disease & rapid access hub. Design, service and infrastructure plan white paper identifying key implementation areas for innovative cardiac services. Three core implementation points are identified on the left (green). Three core service points on the right (red), where health hubs must: firstly, navigate existing health system strengths for treating patients, however innovation could see greater range of care within communities; secondly, reform may be required to address questions of partnerships between private and public sectors and sharing of workforce across the health spectrum, which have been relatively untested [34, 42].