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Interdisciplinary Team-Based Disease Management of Heart Failure

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Author Info

  • Thomas G. Di Salvo

    (Partners Health Care System, Boston, Massachusetts, USA)

  • Lynne Warner Stevenson

    (Partners Health Care System, Boston, Massachusetts, USA)

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    Abstract

    Multidisciplinary team disease management has evolved into consensus `best practice' in the care of patients with 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 multidisciplinary 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.

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    Bibliographic Info

    Article provided by Wolters Kluwer Health | Adis in its journal Disease Management & Health Outcomes.

    Volume (Year): 11 (2003)
    Issue (Month): 2 ()
    Pages: 87-94
    Download reference. The following formats are available: HTML (with abstract), plain text (with abstract), BibTeX, RIS (EndNote, RefMan, ProCite), ReDIF
    Handle: RePEc:wkh:dmhout:v:11:y:2003:i:2:p:87-94

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    Web page: http://diseasemanagement.adisonline.com/

    For corrections or technical questions regarding this item, or to correct its listing, contact: (Dave Dustin).

    Related research

    Keywords: Disease management programmes; Heart failure;

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