1. Identify Heart Failure Phenotype and Risk Level
- Confirm diagnosis: HFpEF / HFrEF / HFmrEF
- Review recent echo, BNP/NT-proBNP
- Assess NYHA class (functional status)
- Identify high-risk groups:
- Recent hospitalisation
- Multiple comorbidities
- Poor medication adherence
- Frailty or cognitive impairment
2. Initiate Structured Patient Education
- Provide clear explanation of HF, triggers, and expected symptoms
- Teach daily symptom and weight monitoring
- Alert threshold: >2 kg weight gain in 2 days
- Promote medication adherence understanding
- Use visual aids, handouts, and teach-back methods
- Share Heart Foundation patient resources:
3. Manage Fluid and Sodium Intake
- Fluid restriction:
- If symptomatic congestion: suggest 1.5–2.0 L/day
- Sodium restriction:
- Recommend <2 g/day sodium intake
- Provide list of high-salt foods to avoid
- Refer to dietitian for detailed meal planning
4. Implement Daily Weight Monitoring
- Ask patients to:
- Weigh daily (same time, scale, clothing)
- Keep a weight diary
- Set up a threshold action plan:
- 2 kg over 2 days → contact GP
- Reinforce at each follow-up
5. Schedule Structured Follow-Up
- Post-hospital discharge: review within 7–14 days
- Frequency:
- 2–4 weekly if recently decompensated or medication titration ongoing
- 3–6 monthly if stable
- Use visits to:
- Assess symptoms and congestion
- Reinforce self-management
- Monitor weight, renal function, electrolytes
6. Collaborate with Specialist and Allied Health
- Refer to or coordinate with:
- Heart failure nurse
- Cardiologist
- Pharmacist (medication reconciliation, adherence)
- Dietitian
- Exercise physiologist / cardiac rehab
- Consider nurse-led titration clinics if available
- Use GPMP/TCA (MBS 721/723) to facilitate care planning
7. Address Comorbidities and Psychosocial Factors
- Optimise:
- Blood pressure
- Diabetes control
- AF or CKD management
- Screen for:
- Depression/anxiety
- Frailty and falls risk
- Cognitive impairment
- Encourage carer and family involvement
- Use MBS mental health plan or My Aged Care referrals if needed
8. Prescribe Individualised Exercise Plan
- Recommend moderate-intensity aerobic exercise (e.g. walking)
- Refer to cardiac rehab where available
- Encourage:
- Endurance: 30 min/day, 5x/week
- Resistance: 2x/week if able
- Tailor to NYHA class and stability
9. Use Action Plans and Written Instructions
- Provide a written heart failure action plan:
- Daily routines
- When to seek help
- Medication adjustment instructions (e.g. sliding scale diuretics)
- Ensure the patient and carers can read and understand the plan
10. Document and Bill Appropriately
- Allied health referrals
- Document:
- HF education, weight monitoring advice, fluid/sodium goals
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