Home visits as part of the heart failure nursing service

Article by Renee McEwing: 2016 Cardiovascular Nursing Scholarship recipient

In 2016 I received the CSANZ NZ Region Cardiovascular Nursing Scholarship. I used the scholarship to observe home visiting programmes for heart failure patients in Sydney to investigate the efficacy of developing a similar programme in Counties Manakau. I spent two weeks working with teams of nurse practitioners in the home visiting services of Prince of Wales Hospital and Saint Vincent’s Hospital.

Rapid increase in incidence of heart failure

With the rise of the ageing population, the incidence of heart failure has rapidly increased. The Counties Manakau Health (CMH) Heart Failure (HF) service currently consists of inpatient education, outpatient up-titration clinics, a supervised exercise programme, and an implantable cardioverter defibrillator (ICD) support group. As rates of heart failure continue to increase, our approach needs to be focused on keeping patients well and at home for as long as possible. In order to do this across the trajectory of this syndrome, the HF service needs to be sustainable with the ability to provide a multifaceted approach delivering care across the primary and secondary sectors. Skilled nurses can increase access to evidence-based care, ensure patients are on gold standard therapy in a timely manner, and empower patients and their whanau to self-manage their condition.

Studies demonstrate value of home visiting programmes

Across District Health Boards in New Zealand, some services extend their reach to home visits, and the efficacy and cost-effectiveness of this approach has been examined in the literature. One systematic review showed reduction in unplanned hospital visits and length of stay (Huntley, Johnson, King, Morris & Purdy, 2016), and another reported reduced mortality and increased days out of hospital and alive (Stewart et al., 2016).

Observations on home visiting services in Sydney

From my observations working with teams in the home visiting services of Prince of Wales Hospital and Saint Vincent’s Hospital in Sydney, home visiting appears to be a useful model particularly in end-stage HF, and in the context of frailty and social isolation in order to reduce readmissions. Although home visiting is a costly approach, savings from fewer readmissions are significant. Allied Health support the enhanced service delivery in this setting. However, clinical support from medical staff in a formalised fashion is essential in order for nurses to be able to manage patients in their home, especially for non-prescribers.

Access to HF nurses via a designated phone proved useful in enhancing patient self-management and appeared to be a great link between primary and secondary care. Episodes of HF deterioration were preempted and treated early with IV frusemide in the home, further reducing hospital admissions. Remaining active in the multi-disciplinary team when patients reached the palliative phase of HF increased the continuity of care and better diuretic monitoring.

Conclusion: home visits have a role in heart failure management

Home visits have a role in HF management in the community. The geographical area covered by the services observed in Sydney was smaller than CMH which reduced driving time, and the HF population at CMH is significantly younger with more patients being able to attend clinic. Home visits are beneficial in preventing readmissions and increasing quality of life for some patient populations. The CMH HF service is exploring options to increase integration with primary care.

Acknowledgment

I would like to thank CSANZ for this invaluable opportunity that has benefited both my personal career development and service delivery at CMH.