The Virtual Heart Failure Service is a pioneering, first-of-its-kind model within NSW, delivering comprehensive heart failure care entirely virtually without reliance on traditional in-home or clinic-based visits.
Codesigned with input from patients, clinicians and primary care providers, the model aligns with national and state heart failure care guidelines.
The aim of the Virtual Heart Failure Service is to:
- enhance specialist post-discharge care
- support patients to navigate care
- reduce length of hospital stays
- prevent readmissions.
Heart failure cases continue to rise
Heart failure places a substantial burden on both patients and the healthcare system, with high rates of hospital readmission often linked to limited access to specialist follow-up and under-use of guideline-directed therapies. The burden of heart failure is disproportionately higher among First Nations people, older populations and those living in rural and regional areas. This is reflected in Hunter New England Local Health District (HNELHD), where the prevalence of heart failure continues to rise. The district also reports higher rates of mortality, hospital readmissions and sub-optimal adherence to guideline-directed therapy compared to national benchmarks.
Prior to the establishment of the service, heart failure care within HNELHD was fragmented across 3 geographically separate services. Each operated in isolation, with differing referral criteria, clinical interventions and outcome reporting.
The service was developed through a clinical redesign project in direct response to local reviews identifying poor outcomes and service gaps in heart failure care. Through extensive stakeholder consultation – including consumers, clinicians, and both primary and secondary care providers – the redesign process highlighted critical gaps in care coordination, medication management, end-of-life care and patient education.
In 2024, the service was unified into a single, district-wide offering which significantly enhanced reach and consistency. Today, the service supports over 70% of heart failure patients discharged from HNELHD hospitals.
Using a collaborative and multidisciplinary approach
HNELHD established the service to transform post-discharge care and reduce variation in access and outcomes. The service provides patients with timely access to a Heart Failure Clinical Nurse Specialist and/or Transitional Nurse Practitioner, improving:
- uptake of evidence-based therapies
- care coordination
- integration between primary and secondary care.
Patients and carers are supported in a culturally safe, person-centred environment that prioritises health literacy, education, self-management and system navigation. The Transitional Nurse Practitioner also conducts face-to-face assessments for high complexity patients, facilitating early intervention to reduce length of stay and prevent avoidable readmissions.
The service uses a collaborative, multidisciplinary approach and makes efficient use of existing resources. Weekly 'huddles' bring together diverse teams – cardiac rehabilitation, Aboriginal health, service clinicians, and other key stakeholders – to share knowledge, provide peer support, and strategically plan patient care. These meetings prevent care duplication, streamline service delivery and ensure patients receive timely, appropriate care based on their clinical and personal needs.
In June 2024, the addition of a Transitional Nurse Practitioner based in Tamworth further expanded service capacity, particularly in rural and regional areas. The role enabled advanced clinical support and the management of complex cases remotely. Clinical oversight of the Transitional Nurse Practitioner is undertaken by local cardiologists, ensuring quality and safety of care.
Cardiology clinical nurse consultants and local cardiologists provide service and clinical oversight, ensuring quality and safety of care. Operational line management at individual hospital sites ensures consistent care delivery while providing flexibility to meet local needs.
Reducing readmission rates and service duplication
In 2024, more than 800 patients were referred to the service, resulting in over 3,000 individual patient contacts, not including collaborative engagements with general practitioners, cardiologists, and referrers.
Since centralisation in 2024, the service has:
- contributed to a lower hospital readmission rate of 8–10% – less than half the national average of 22%
- contributed to a reduction in average length of stay for heart failure patients
- improved heart failure care and reduced service duplication.
There has been no increase in essential admission days – representing significant fiscal savings, with the average heart failure admission costing $1,806 per day.
The service is a cost-effective, transformative model that improves the post-discharge experience and outcomes for patients. It has now been implemented in two-thirds of HNELHD facilities. Each site benefits from ongoing education, clinical support and a dedicated virtual heart failure nurse.
The service exemplifies high value for money by improving access, consistency and outcomes through a clinician-led, collaborative model that maximises existing resources and delivers equitable, high-quality care across the district.
