Take It To Heart

Greater Western Area Health Service

Abstract

All patients with Chronic Heart Failure should have access to comprehensive hospital or community based rehabilitation individually tailored to their needs. Rehabilitation should include physical activity, education and psychological and social assessment and draw on multi-disciplinary expertise (NSW Health, 2003).

In Rylstone, a small town in western NSW, 8 clients aged 62 to 80 years with a history of cardiac and pulmonary disease participated in a program aimed at actively involving them in self management post cardiac and pulmonary episodes.

Weekly two hourly sessions involved education, exercise and social inclusion and empowerment. Pre an post assessments using six minute walk tests, get up and go test, spirometry and SF 36 Health Survey.

The results reflected positive outcomes in 100% of participants.

Aim

• To support and educate clients post cardiac event or procedure.
• Reduce unplanned presentations to hospital by promoting self management.
• Emphasise life management  rather than diagnosis intervention

Nature of the Problem

• Emergency Department staff identified cardiac and pulmonary clients were re-presenting to hospital with issues that could be better managed in a community setting.
• Many presentations were recognised as related to stress or a lack of follow up after discharge from tertiary centres.
• Difficulty accessing cardiac pulmonary rehabilitation owing to long distances to the nearest rehabilitation centre. 
• Limited number of cardiac clients at any one time in the area was not adequate to sustain resources needed to maintain a specialised cardiac rehabilitation program like those in large cities. 

Extent of the Problem

• Attending similar programs in large regional cities such as Bathurst (closest available) would involve a round trip of 240 kilometres for clients from this area.
• Access to community transport is limited by availability and affordability.
• Chronic illness in clients precludes travelling long distances.
• Limited resources in small rural towns would normally restrict such programs.

Strategic Importance

• Early intervention following a procedure or diagnosis in care of a client with chronic illness by primary health staff will assist in reducing the re-presentations made to Rylstone Hospital Emergency Department, hospital admissions and on occasions, transfers to larger centres.
• Communication networks established to enable referrals from other clinical health services also assists in further development of current program using those resources.

Planning and Implementing Solutions

This local based program addressed the existing gap in the client’s continuum of care.  Combining pulmonary with cardiac clients and adapting the program to an overall lifestyle improvement emphasis addressed this issue.

This was achieved by:

• Obtaining early/prompt referrals from Emergency Dept and acute wards.
• A Myocardial infarct pathway was implemented, which prompted staff to commence the referral process despite the patient was being transferred out for definitive care.
• Conduct a weekly exercise program to promote physical activity as part of each client’s daily routine towards better health.
• Conduct education sessions in conjunction with the exercise classes to promote self-management skills.
• Communicate with all Area Health Services to provide integrated and co-ordinated client care.
• Refer clients to allied health as necessary to prevent/detect health problems early.
• Encourage clients to use their red Medical Information booklets to maintain communication and ensure that information is shared across hospital and community care settings.  Clients can then take an informed part in their care, which will assist towards developing self-management skills.

(Self-management – Involves the person with the chronic disease engaging in activities that protect and promote health, monitoring and managing the symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes. The Centre for Advancement in Health, 1996)

Outcomes and Evaluation

Evaluations are based on:

• Pre and post measurements taken to assess for improvement.
• Clients asked to complete an evaluation form.

Pre and post measurements are based on:

• A general medical assessment.
• An explanation of the Borg Scale. This scale can be used by the client to rate their exertion level. The Borg scale is one of the preferred methods for assessing exercise intensity in clients who are prescribed medications that affect heart rate.
• Exercise capacity using the six minute walk test, and Get up and Go Test.
• A spirometry to assess lung function in pulmonary clients
• Filling out the pre and post program form.
• Explanation of the exercise program and tick sheet.
• The client to fill in the SF-36 form. This is a general health survey and includes limitations to physical & usual activities because of health problems, bodily pain, general health perception, vitality, limitations in social activities due to physical or emotional problems, limitations in usual role activities because of emotional problems and mental health.

Since commencing the program, only one participant has presented to the emergency department for cardiac related symptoms.

Sustaining Change

1.Communication systems in place between health professionals to ensure continued support and referrals to the program, including:

• Rylstone Hospital Emergency Department
• Rylstone Hospital Acute Wards
• GPs
• Allied Health
• Community Health
• Self – referrals

2.Communication systems will be supported by the change management processes involved in the HealthOne project at Rylstone. An integration coordinator is being recruited to assist with management of chronic and complex care clients, and to promote the NSW Health Integrated Primary and Community Health.

Future Scope

This program could be replicated and implemented in other small rural towns across NSW using limited resources.

References

NSW Department of Health (2003) NSW Clinical Service Framework for Heart failure.  A practice guide for the prevention, diagnosis and management of Heart Failure in NSW.Vol 2.

Contact

More about the 2008 NSW Health Awards