Co-design of an integrated care solution for Heart Failure  in socioeconomically disadvantaged populations in Northern Adelaide, Australia

Background: Chronic conditions, such as heart failure disproportionately affect socioeconomically disadvantaged populations in Northern Adelaide, South Australia where gaps in care coordination and service accessibility have been identified. These challenges in accessing services contribute to delayed symptom recognition and result in frequent emergency department presentations.

 

Approach: This multi-methods study adopts an Integrated Knowledge Translation approach, incorporating journey mapping1 and co-design methodologies2 to develop an integrated care solution tailored to the needs of individuals with Heart Failure.

 

The study comprises eight phases: (1) Formation of an advisory group, (2) Mapping of population health data, (3) Environmental scanning of service touchpoints through stakeholder engagement, (4) Qualitative interviews with consumers to identify their journeys of receiving care and perspectives of opportunities to improve the coordination and experience of care, (5) Development of journey maps, (6) Co-design workshops with stakeholders including patients, health and social care providers, (7) Pilot testing of the solution, and (8) Final translation workshop to refine and prioritise scale up of the intervention.

 

Results: To date: Population data has been synthesised with people with Heart Failure in the region commonly male, aged 65 years and above, taking 5 medications, have at least two other comorbidities, BMI Overweight or higher. Stakeholder engagement has occurred with cardiac specialists, Heart Failure Nurses, General practitioners, Allied health, Council and social care providers to develop a visual service mapping. This map indicates a vast number of chronic disease prevention and management services available for individuals with Heart Failure in Northern Adelaide, including inpatient, outpatient, in-home services and community supports led by local councils.

 

Telehealth and remote services are also available. General practitioners act as the regular touchpoint to refer onto service with individuals often seeking medical support for other chronic conditions (not Heart Failure). The stakeholder engagement has already indicated a gap in awareness of services across sectors. Initial data from qualitative interviews of patients with Heart Failure describe the majority of services received are referred to by Cardiologists, and limited community or council supports accessed.

 

Counselling support groups and in-house supports were valued and it is viewed as positive when healthcare professionals communicated with each other well about care. An individualised visual patient journey map has been developed for each participant.

 

Implications: All findings when completed will highlight a systematic approach to co-designing a solution that connects individuals to the services that are available, to support the integrated management of chronic conditions, including Heart Failure. This approach can be used internationally to guide the development of care solutions tailored to individual settings and conditions, to improve experiences and outcomes, promoting integration.

 

References

1. Joseph AL, Monkman H, Kushniruk A, Quintana Y. Exploring Patient Journey Mapping and the Learning Health System: Scoping Review. JMIR Hum Factors. 2023;10:e43966.
2. Graham ID, Kothari A, McCutcheon C. Moving knowledge into action for more effective practice, programmes and policy: protocol for a research programme on integrated knowledge translation. Implementation Science. 2018 Dec;13:1-5.