Heart Helper Pilot – Health service and patient stories

Bendigo Health’s story 

The Bendigo Health Hospital Admission Risk Program (HARP) receives referrals for heart failure patients following acute hospital admission and from outpatient and GP clinics. The SCV Heart Helper team is a tailored service that works collaboratively alongside the HARP team to provide additional resources and supports for people with heart failure in their home. The aim of the Heart Helper team is to enhance the individual’s quality of life, improve their health outcomes and reduce emergency department presentations and unnecessary hospital admissions.

To achieve these aims, streamline the referral process and respond to client needs the Heart Helper care plan includes: 

• 24–48-hour follow-up call after hospital discharge or referral. This is a welfare check to ensure clients are safe, understand their discharge instructions and are coping well at home.
• Home visit within 3-5 working days by their HARP Care Coordinator which encompasses a detailed health assessment (Flinders Chronic Disease Model), baseline KCCQ12,education according to the ‘Heart Foundation Living well with Chronic Heart Disease’ and the Heart Health Monitoring Diary (a traffic light diary that helps clients recognise early weight and symptom changes and correlates with the Diuretic Actions Plan).
• A management plan is commenced and each client decides on a personalised self-care goal of ‘What matters to them’. This goal is the basis of the Heart Helper care – the aim being to help the client meet their self-care goal. 
• Client is referred to Heart Helper program by the Care Coordinator and receive regular home visits as per their individual needs.

The Heart Helper team works with each client and focuses on their self-care goal. They help to:

• Identify barriers and increase self-management capability
• Improve client knowledge of heart failure, medications and treatments
• Improve the clients experience and ongoing quality of life
• Maintain or improve access to specialised heart failure care
• Ensure clients feel supported once discharged home from hospital

The additional care in the home has seen a substantial reduction in all-cause 30-day hospital admissions (from 30% to 16%) and a statistically significant improvement in patient reported outcome measures. 

The SCV Heart Helper Pilot has now transitioned to a permanent HARP Enrolled Nurse position. This continues to aim at supporting the client in the community, to keep them well in their homes and reduce emergency department presentation and unnecessary hospital admissions.

Royal Melbourne Hospital’s story

The cardiology department at The Royal Melbourne Hospital (RMH) developed a hybrid 12-week heart failure rehabilitation program to ensure more patients had access to heart failure rehabilitation. Heart failure rehabilitation is essential in providing structured exercise and education to people living with heart failure and early access to rehabilitation after hospitalisation is increasingly recognised as important in preventing deconditioning and other negative consequences of reduced physical activity. 

Existing rehabilitation programs already serviced a proportion of heart failure patients at RMH however, not all of our patients were eligible for these services. We wanted all of our heart failure patients to have access to a rehabilitation program after discharge. Our approach was to incorporate home visits and telehealth appointments in the first 12 weeks after discharge that focused on restoring function, mobility and exercising in a safe and timely way. 

The overarching goal of the program was to help support the transition from hospital to home and coordinate care with a multi-disciplinary team consisting of: allied health, nursing and pharmacy staff. We worked closely with medical specialities from Cardiology and General Medicine and our staff assisted patients with attending appointments, understanding their action plan and recognising early deterioration in the community. 

This pilot also uncovered barriers to receiving care in the immediate post discharge period, for example lack of technology or internet access. The cardiology department worked with the RMH foundation to develop a lending program where patients could borrow an iPad, blood pressure device and oxygen saturation monitor from the cardiology department so that more people with heart failure could access treatment in the comfort of their own home. 

The model of care was widely accepted by our consumers who reported they were pleasingly surprised by the impact increasing physical activity and exercise had on their well-being and overall quality of life. The pilot has also been well received by clinicians and the learnings will help to transform the way heart failure rehabilitation is delivered at RMH.

Northern Health’s story

What did our model of care entail?

Northern Health Hospital Admission Risk Program (HARP) department worked collaboratively with Safer Care Victoria to develop a new model of care incorporating alternative workforce into a specialised heart failure area of care to reduce hospital admissions, representations and to improve patient reported outcomes.

The new model of care has introduced an Enrolled Nursing workforce working alongside Clinical Nurse Consultants (CNC) and aims for a holistic approach in heart failure patient care.

It involves several aspects that this project has introduced:

• Post discharge 48-hour phone call follow-up. The phone call aims at targeting vulnerable patients in the transition phase post hospital discharge, answer any arising questions as well as identifying any urgent issues.
• Introduction of Heart Helpers by CNC at first home visit.
• Heart Helper (Enrolled Nurse) home visit to take place as soon as possible and as often as requested by the client.
• Introduction of social prescribing into a client’s care, which involves taking a step away from the regular heart failure education and taking more into an account of ‘what matters to the client’ and what are their needs and likes.

What impact did the pilot have for our patients?

Many clients have enjoyed having closer, more personal interaction with Heart Helpers. It helped to:

• Identify certain barriers to optimised client care
• Improve patient adherence to medication management
• Improve patient understanding of heart failure
• Reduce social isolation
• Improve client access to specialised care
• Improve client experience and reported outcomes 

In addition, our clients enjoyed sharing their life stories and social gatherings with the Heart Helper Team. 

What did we learn? 

• Clients feel more accepted and more valued
• Clients have a better understanding of heart failure when provided in a different format: games, puzzles, crosswords, teach-back method
• Clients need time to accept heart failure diagnosis and often a gentle approach
• Clients have a multitude of co-morbidities and often require discussion about different aspects of their health care
• Post discharge phone call important to mitigate some of the early post-discharge issues

No pressure with the Heart Helper Program - Alan and Faith’s story

Alan and Faith had no idea what to do when Alan was diagnosed with heart failure. We were like ‘fish out of water’, says Faith. I am speaking with Faith today, Alan’s carer. Alan is also present, in the background, and joins in occasionally to emphasise some points about the Heart Helper Program that has guided them at home in the last four weeks.  

The Heart Helper Program aims to support people and their carers after being in hospital with heart failure. It is a home-based program, that offers support, education and management strategies targeted to individual needs. ‘We aim to reach heart failure patients that struggle with their diagnosis and understanding of their disease’, says Janet a Heart Helper team member. 

Alan and Faith were happy chatting about the Heart Helper Program. They say the Heart Helper team explained what heart failure is and helped them understand what all the tests and forms that had previously received were for. ‘The Heart Helper team explained it all to us in a way that we understood’, says Faith.

‘There was so much going on during the early stages of heart failure and then Alan was also diagnosed with diabetes. We didn’t know if we were doing the right thing’, says Faith. ‘It took us about 4-6 weeks until we started to feel that we were getting on top of things. This had a lot to do with the guidance of the Heart Helper’, explains Faith. ‘They were very reassuring and checked with me to see how I was coping as a carer. This support was very encouraging. They said that I was doing all of the right things for Alan’, says Faith.   

‘At first, Alan was prescribed a lot of medication and we didn’t know what they were for, so the Heart Helpers explained what each medication was, and when to take it’, says Faith. Alan has now decreased his medication as his condition improves. 

Alan had an incident when he had sudden weight gain. This occurred when he was preparing for a test and he went off his fluid tablets. He put on 2-3 kilos in 3 days – a warning sign for many people with heart failure. They were concerned, so Faith put him back on the medication and was reassured by the Heart Helper, that this was the right thing to do. 

Alan lost his appetite, and this was stressing them both out. ‘He was hardly eating. The Heart Helpers talked to him about other food options like Sustagen and diet energy drinks. This helped a lot’, says Faith. After this, they stopped worrying about it and Alan improved.  

‘The Heart Helpers were invaluable to us, they never rushed us. There was no pressure, they were not checking the clock like they do in the hospital, we felt supported’, says Faith.  

‘Alan is still not 100%’, says Faith. Alan is considering joining a heart failure exercise program recommended by the Heart Helper team, who also arranged a diabetes educator to visit him at home when he had further testing for diabetes.

They have come to the end of the program, but Alan and Faith feel that the guidance will continue as Alan is still being treated for heart failure. ‘He had a lung function test last week and Janet, the Heart Helper called him to see how he was going’, says Faith. This is very reassuring to them both, as they feel they are not alone. ‘We wouldn’t have got there without their help. We could end up in hospital without the Heart Helper team’, says Faith.  

-Katerina Yakimov, SCV Lived Experience Partner for the Heart Helper Pilot 

Betty discovers a little gem with the Heart Helper Program

‘The Heart Helper is a little gem, you can talk to her about anything’, says Betty. The Heart Helper program has come into Betty’s life at the right time. She has had a rollercoaster experience of things going wrong with her health and her family that left her struggling to regain her health and her home.  

The Heart Helper program is a targeted home-based service that supports individual heart failure patient needs. ‘We aim to reach heart failure patients that struggle with their diagnosis and understanding of their disease. They may have multiple diagnoses, live alone without the support of a carer or family member and may be culturally or linguistically diverse’ says Margaret, a Heart Helper team member that has been visiting Betty. 

Betty did not know that she had heart failure. She initially didn’t see the diagnosis on her discharge summary (that was given to her family), and missed follow-up appointments that she was not aware had been made. 

Betty’s issues started about 12 months before, when she collapsed at home. She lay on the carpet for 4 days until she was found. She experienced delirium, couldn’t remember the year, or what money was. She knew her brain was not functioning as it should. She was hospitalised for 2 weeks, followed by rehabilitation for another 2 weeks. For 6 months, Betty felt that she was in the dark, not knowing what was happening. Family took charge of her care and tried to put her into a nursing home. 

Betty was able to make some changes, had a pacemaker put in, and is now back home and getting back into her former life. She has had a range of health support including hospital in the home and the Heart Helper program. She lives alone and doesn’t have much physical or mental health support. She feels her family are not really interested in her, they just want her to be better. ‘No-one really asks me, about what happened’, she says. 

This changed when Betty met the Heart Helper team. ‘They were interested in what happened to me, they let me talk about it’, she says. ‘They explained what heart failure is. They observe me, take my blood pressure and talk to me about my medication’, she explains. This has been really helpful because her medications have changed. ‘It is good for someone to check up on me at home, as it is easy to slide into a worrying state’ she says. 

The Heart Helper team has ‘made me feel that you can go back into the world, I feel that I can go to the shops or a swim. Last Saturday I went to the bowls club without worrying about it, and watched a game, as I used to play’, she says. Betty doesn’t belong to any social groups or activities because she goes through periods of being unwell. 

She recently had a bout of sciatica pain in her leg, which was very painful. Despite many efforts, and hopping on one leg, she couldn’t see a doctor in her local area as they were all booked out for many days. She was at her wits end. Then Margaret, a Heart Helper team member, arrived on a Wednesday on her regular home visit and took her to the hospital where she was instantly admitted. The pain in her leg lasted for 5 weeks. ‘Margaret made me feel like a person again and the follow up has been fantastic’, she says.   

Betty has had a lot of therapy she says and people do understand what happened to her. This is important to Betty as it acknowledges her experience. For a while there she was considered to be incompetent and she felt trapped in her situation. She thinks a direct follow-up after hospital with her, rather than her family, might have been a better outcome for her. She feels that she was really disconnected from her care and follow-up during this time. 

Life is good again for Betty. She is planning on going swimming tomorrow at the local pool and perhaps she may join a heart failure exercise group. She is looking forward to the Heart Helpers final visit. ‘This is the best part as she allays all of my fears.’ 

-Katerina Yakimov, SCV Lived Experience Partner for the Heart Helper Pilot 

Jennifer is ticking all the right boxes with the Heart Helper Program 

Jennifer is very satisfied with the support she was provided, as she explains her positive experience with Bendigo Health’s Heart Helper Program. When I met with her, she had just completed the 4 week program. During this time, she feels that she has learnt a lot, and is better equipped with new skills and understanding of how to manage heart failure.

The Heart Helper Program aims to assist and support people with heart failure and their carers at home, immediately after going home from hospital. It is a home-based program, that offers support, education and management strategies targeted to individual needs. The goal is to help people stay home longer and reduce emergency department presentations and readmissions to hospital.   

After Jennifer was discharged from hospital, she recalls receiving follow-up pretty much straight away. ‘I have never experienced such a knowledgeable and reliable service like the Heart Helper before. They were so easy to communicate with’, she says. The Heart Helpers, ‘explained so much to me, about heart failure and what I could do to manage better at home’, she says. She now keeps a diary, where she records her blood pressure, fluids and weight. ‘I felt reassured by their guidance and suggestions. They told me about home help and aides in the home that could help me with home tasks. I now have these services on a fortnightly basis’, she says. 

Jennifer was also offered rehabilitation and a dietician. She does her own cooking and paces herself to do the house keeping. While social outings were discussed during the weekly Heart Helper visits, Jennifer considers herself more of a homebody. She has her grandchildren and in-laws that come and go she says. ‘There are many activities with the grandchildren. Their antics keep me entertained, they are the best thing’, she says. She also goes out for the occasional coffee and brunch. 

She has just finished with the Heart Helper, but she knows that she can contact the Heart Helpers again if she needs to. This is very reassuring for her to know.  

-Katerina Yakimov, SCV Lived Experience Partner for the Heart Helper Pilot 

What I got was great - Rhonda’s experience of the Heart Helper Program

Rhonda did not know that she had heart failure until she was part of the Heart Helper Program. She now understands she has had symptoms for many years, and tests years ago would have been to confirm the diagnosis. This is also compounded by her other conditions that impact her life, or ‘restrictions’ as Rhonda calls them. She has vocal cord disfunction, problems with her neck, chronic arthritis, asthma, kidney failure and suffers from long COVID. Rhonda had a carer, her daughter who looked after her, but she died a few years ago. She doesn’t have many social outlets, needs help with things like washing her hair and getting groceries, and is waiting on a home care package. 

The Heart Helper Pilot is a targeted and tailored service that supports heart failure patient needs. ‘We aim to reach heart failure patients that struggle with their diagnosis and understanding of their disease, who may have multiple diagnoses, live alone without the support of a carer or family member and may be culturally or linguistically diverse’ says Mustafa a Heart Helper team member. 

Rhonda feels that she goes to see her doctor regularly for asthma management and often lands in hospital every winter. Last time she was in hospital it was as a result of fluid build-up in her lungs from her heart failure.  

When Rhonda met the Heart Helper team she was having a succession of cancelled speech therapy appointments without any explanations. This led to Rhonda feeling down, especially when the third appointment was cancelled. She was gasping for breath, and travelling to appointments was not easy for her. The Heart Helper team worked with Rhonda and organised a speech therapist to come to her home. Breathing is a lot easier now her heart failure condition has improved and she has started speech therapy, and she is not gasping for breath like she used to. 

She felt that when she was in hospital, everything there was rushed.  She felt like a number there. People were running from one patient to another. So, when she was referred to the Heart Helper team who came to her home and patiently talked to her in a way that she understood about heart failure, this was a welcome relief to her, ‘to feel like she mattered’ she explains.  

‘A typical appointment with the Heart Helper would involve a chat, and they would take my temperature, listen to my heart, check my blood pressure and they even fixed my electronic weighing machine’, she says. Now she can check her weight everyday on her phone. The Heart Helper team ‘has treated me like a person again, and not a number’, she says. The Heart Helper Program aims to assist and support people with heart failure and their carers at home, immediately following discharge from hospital.  

The Heart Helper team worked with Rhonda for an extended time, helping her in many areas including getting a taxi card. She still cannot walk very far because she gets out of breath. ‘I need to exercise’, she says, saying she now understands the importance of it thanks to the Heart Helper team. She saw a program on the phone about chair-based exercises for seniors that she feels she would like to try. 

‘What I got was great’, Rhonda says about the Heart Helper program. ‘It should continue especially for the elderly who need the personal one to one contact.  You do not get this in a hospital. It is a very professional service but it doesn’t feel clinical at all’, she says.   

-Katerina Yakimov, SCV Lived Experience Partner for the Heart Helper Pilot

Wilma’s story – living with heart failure

Wilma is living with heart failure. Wilma uses a walker to get around and has some home help with showering, cleaning and shopping. She does the other household tasks herself, ‘slowly and at her own pace’, she says. ‘Even though I had tests done, nobody told me anything, until Hannah the Heart Helper explained it to me, in a way that I understood about heart failure’, says Wilma. ’I am not as breathless as I used to be, and my sleeping is alright too’, explains Wilma.  

The Heart Helper Program aims to assist and support people with heart failure and their carers at home, immediately after discharge from hospital. It is a targeted and tailored service that supports individual heart failure patient needs. ‘We aim to reach heart failure patients that struggle with their diagnosis and understanding of their disease. They may have multiple diagnoses, live alone without the support of a carer or family member’ says Hannah, a Heart Helper team member that has been visiting Wilma. 

At first, it was daunting for Wilma when she returned home after being in hospital and in respite. When she was in care as she puts it, ‘you don’t have to do anything yourself, as it is all taken care of like the meals, laundry and the cleaning. Back at home, I need to think about what I am doing, the cooking, eating and the washing. I can’t eat a lot of carbohydrates one day, and then only salad the other day. I am also a diabetic’, she says.    

‘My weight goes up and down and I have water restrictions. Every morning, I weigh myself and if I put on 2-3 kilos then I know to call the hospital’, says Wilma. The Heart Helper team has helped her understand how to manage her water restrictions, like on hot days. ‘The Heart Helper reassured me, that I am doing the right thing in how I am managing at home. If I am worried about anything, Hannah, the Heart Helper would explain it to me and this settled me’, she explains.

Wilma is still doing the exercises that she was given in respite but doesn’t walk much, just around the house, as it has been too hot to go outside and wants to avoid catching COVID-19. She relies on transport and taxis to get around to health appointments and other outings like the hairdresser. 

Wilma is happy at home. She feels that she is now managing at home and that she is ‘still with it and there is no place like my home’, she says.

-Katerina Yakimov, SCV Lived Experience Partner for the Heart Helper Pilot