Examples of what has been done

Multidisciplinary care programmes providing person-centred, adaptive care

Overview

St. Michaels Hospital Heart Failure Unit offers a multidisciplinary programme that aims to improve the quality of life of patients with HF and ensure that patients are offered evidence-based care in accordance with their individual needs.

What they did

The Heart Failure Unit provides patients with evidence-based, multidisciplinary care, education and support. It encourages and supports patients and their families to get involved in their own care and respond to possible worsening of their condition.1

The HF unit multidisciplinary team consists of cardiologists, advance nurse practitioners, clinical nurse specialists, physiotherapists, psychotherapists, dieticians and administrative staff, with one health care specialist who is trained in palliative care. The team is also involved in communicating with other health care providers for smooth transitions between primary and secondary care.

Links, references, and key reading