This project aims to explore the process of care transition from the acute hospital admission to the community, in older patients (> 65) admitted to RMH with a primary diagnosis of CHF.

It has been identified that chronic heart failure is the single most common diagnosis driving readmissions for The Royal Melbourne hospital. And for patients aged 65+, congestive heart conditions are ranked second in the top 5 potentially avoidable hospitalisations for The Royal Melbourne hospital.

The project has two distinct phases and seeks to answer the following questions:

1. Are there clinical or demographic differences between patients with a single admission, with a primary diagnosis of CHF, compared to those with multiple admissions with a primary diagnosis of CHF, over a one-year period?
2. Can the transition of care from the acute hospital to the community be improved for patients with Chronic Heart Failure (CHF)?

Identifying these differences in clinical and demographic characteristics will allow more accurate identification of patients with increased risk of readmission, who should be targeted more aggressively during their inpatient stay with respect to discharge planning and community care.

The input of patients, Emergency Department staff and general practitioners will be sought via focus group interviews in order to determine common themes and whether possibilities for improvement in the transition of care exist.

This project has been funded by a Department of Health and Human Services grant via the Victorian Cardiac Clinical Network. The project is part of a National Heart Foundation/Department of Health Model of Care Collaborative (MOCC). The broad aim of the MOCC is to improve management of heart failure across Victoria.