Interdisciplinary Team-Based Management of Heart Failure

摘要

Multidisciplinary team disease management has evolved into consensus 'best practice' in the care of patientswith chronic heart failure (CHF). The mission of disease management for patients with CHF is to shift care from the hospital to the clinic and to the home, optimize quality of care in concert with consensus guidelines, reduce admissions by 40% and improve functional status and quality of life. The Partners Heart Care program has been operational for 5 years and enrolled hundreds of patients throughout the Partners Health Care System in Boston, Massachusetts, USA. This program enrolls patients following hospital discharge in a physician-directed multi-disciplinary interventional care program, run by nurse practitioners, which incorporates several levels of care dependent upon patient acuity. Following clinical stabilization and optimal titration of oral therapy in concert with consensus care guidelines, patients transition to a longitudinal care program. The primary responsibility for the clinical care of patients in all phases of the program resides with nurse practitioners and primary care physicians, with heart failure specialists serving as consultants on an as-needed basis. Data on pre-specified program outcomes such as quality of care, mortality, hospital admissions, functional status, procedure use and costs are collected prospectively and provide benchmarks for continuous quality improvement. The most critical lesson learned in development to date is the necessity of precise tailoring of the program to local patient and provider needs with local oversight and management.