Heart failure (HF) affects millions of people worldwide. Many patients experience repeated hospital admissions and a poor quality of life, and many die prematurely. The period following discharge from hospital is recognized as a particularly vulnerable time. Effective HF multidisciplinary teams are now recommended in HF guidelines and can improve outcomes, alleviate suffering, and make the overall experience of HF better for patients and their families. Yet audit of HF services reports inadequate levels of adherence with these recommendations and wide variation across countries and regions. This article aims to summarize the key elements necessary for high-quality multidisciplinary care to be provided for all patients, throughout the HF trajectory, from acute hospital admission to long-term follow-up. It also discusses practical approaches to improve communication between the acute hospital and community healthcare teams. These will need to be adapted depending on local needs and resources. These include HF management programmes, structured discharge planning, medicines reconciliation, nurse-led ‘in-reach’ and ‘out-reach’ approaches, and long-term follow-up and monitoring. The importance of involving patients and their families in discharge planning and empowering and educating them in self-care is also discussed. The overall goal is to develop strong multidisciplinary teams that improve patient outcomes, and ensure seamless care is offered to all patients.
from European Heart Journal Supplements - current issue http://ift.tt/2h50LG0
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