Abstract
Introduction: Caredoc Community Intervention Teams (CIT) work closely with local hospitals to establish structured, streamlined referral pathways for suitable patients to be treated at home, thus reducing prolonged hospital admissions and multiple visits. A successful working example of this is the agreed referral process for Heart Failure patients under the care of the Cardiology team in local acute hospitals who do not respond to management with oral diuretics and require administration intravenously. Caredoc CIT nurses have the requisite skills to administer IVs as well as ample knowledge of Heart Failure to identify exacerbations that should be alerted to the Cardiology team.
Aims, Objectives, Theory Or Methods: The referral pathway is a result of communication and strategic planning between Caredoc CIT and the Cardiology team, achieved by reviewing care needs of diverse patients and identifying where potential improvements could be made in the continuing care of people living with Heart Failure with the intention to support them to remain in their own homes as much as possible. Rather than request that patients who require IV diuretics attend hospital they can alternatively be managed safely at home by a CIT nurse, in conjunction with adequate carer support.
Highlights Or Results Or Key Findings: As part of their care plan patients are asked to monitor their weight daily and maintain their fluid balance chart themselves, which empowers them with the knowledge to recognise potential red flags for their condition. An aspect of the agreed inclusion criteria is that patients must attend the Heart Failure clinic weekly for bloods and ongoing review, ensuring that while being cared for at home by CIT nurses, they are continually being monitored by their specialist team, thus reducing potential exacerbations and subsequent admissions. Should a CIT nurse have any concerns regarding a patient they will immediately contact the Cardiology team for review. This integrated approach reduces patient lists awaiting treatment by the Cardiology team, decreases the number of patients needing in-hospital care, which in turn reduces possible risk of frailty from long-term admission for these patients, and supports people to stay in their own home for ongoing treatment.
Conclusions: The aim of this structured referral pathway is to minimise hospital admissions as well as the length of hospital stays for patients with Heart Failure. This process successfully identifies appropriate patients who can receive traditional acute hospital treatment at home, reducing the requirement for hospital services and the associated costs per stay.
Implications For Applicability/Transferability, Sustainability And Limitations: Sustainability of this process is guided by an integrated, systematic approach to proactive care of people living with chronic disease, with the aim to improve delivery methods, reduce the burden on acute hospitals and achieve better patient outcomes.