A heart failure clinic (HFC) in Western NSW is enhancing patient care and improving outcomes by using patient-reported measures (PRMs) to personalise treatment.
Managing heart failure in rural settings differs from major metropolitan centres, because the diverse population in rural areas may require alternate healthcare interventions. Heart failure is a complex clinical condition, which:
- contributes to the burden of disease on patients and health services
- results in hospital admissions and re-admissions
- impacts patients’ quality of life.
In January 2023, a nurse-led HFC was established at Dubbo Health Service in Western NSW Local Health District (WNSWLHD) to improve outcomes for patients with heart failure reduced ejection fraction (HFrEF). The clinic offers an integrated approach to heart failure management through pharmacological and non-pharmacological interventions.
Patients provide timely feedback about their health, symptoms and quality of life, using patient surveys that inform their care. At their first consultation, patients complete the Patient Reported Outcomes Measurement Information System (PROMIS 29) survey. The Kansas City Cardiomyopathy Questionnaire (KCCQ-12) survey is completed before or during follow-up visits to the clinic.
These PRMs promote patient engagement and more positive healthcare outcomes.
Patient-reported measures workflow
The service uses paper-based and digital workflows, depending on patient demographics and clinic volumes. Clinicians prefer to transcribe patient survey responses because it is easy to input them directly into the Health Outcomes and Patient Experience (HOPE) platform. Alternatively, patients can complete a paper-based survey and their responses will recorded in HOPE at a later stage.
PRMs are completed at every consultation to gauge patient improvement or deterioration. For example, the KCCQ-12 survey is a predictor of hospital admission . The clinician reviews, adopts and tailors care based on the PRMs responses. Clinicians discuss care needs with patients during their consultation and refers them on to other specialists if needed.
Consumer story
Jill* is a 61-year-old woman. She has been attending the clinic for around eight months. Jill has a history of atrial fibrillation, hypertension, chronic lower back pain, type 2 diabetes, bronchial asthma, pneumonia and sepsis following a gallbladder infection.
Jill was referred to the clinic following an inpatient hospital admission where she was diagnosed with heart failure. Her ejection fraction was less than 25%.
Jill regularly completed the KCCQ-12 survey during her HFC consultations. This allowed Jill's clinicians to provide tailored assessments and interventions and track her progress. Jill’s heart health has improved significantly since she started visiting the clinic.
* Name has been changed for patient privacy.
Benefits of patient-reported measures
Benefits for the patient
- Increased patient engagement with the service and better understanding of results. This helps when care needs escalate and allows the patient to track their own healthcare outcomes.
- Improves how targeted and efficient healthcare interventions can be and allows for the impact of interventions to be tracked over time.
- Patient-focused care that is responsive to their needs.
- Clinical deterioration is more easily identified through the KCCQ-12 survey, allowing for timely and rapid healthcare intervention.
Benefits for the service
- Access to invaluable data about patient cohorts. This data helps the clinic improve how they work and enhance care delivery.
- Data demonstrates how well the clinic’s patients are doing and the impact the clinic is having. For example, a steady decrease in patients with severe, moderate and mild scores was observed over time (21.5% of patients reported mild to severe scores on their initial KCCQ-12 survey, which reduced to 9% by their third survey).
Benefits for the organisation
- The correlation between hospitalisation and patient’s self-reported severity using the KCCQ-12 survey is well known. The clinic has used this data to reduce the risk of hospital readmission. This also helps the district optimise its resources.
- Data from NSW Health’s Activity Based Management Portal and the KCCQ-12 survey indicates that costs of around $169,000 could potentially be saved. More savings could potentially be made if this model was implemented across WNSWLHD and the wider health system.
Helpful tips for other services
Accountability drivers and targets need to be set from the outset.
Understand what clinicians and patients want from PRMs – what’s in it for them?
In-person education, training, rollout, 'go live' and support is paramount to ensuring success.
Clinical engagement approach
PRMs was implemented in the HFC at Dubbo Health Service using a standard local project management approach.
- Mid-2020: The PRMs team identified the patient cohort and did a scoping exercise with the service. The workflow was developed, and champions were identified to support the change.
- October 2022: The PRMs team planned the training, go-live instructions, follow up and support processes.
- November 2022: The PRMs lead provided KCCQ-12 and PROMIS-29 survey education and training. This included how to use the PRMs, interpretation, relevance, escalation and local decision support.
- January 2023: Go-live occurred, with on-site support provided by PRMs leads.
- February-June 2023: PRMs leads provide continued support for reporting, data use and cost analysis.
Organisational structure
Sponsors: The Executive Director of Quality, Clinical Safety and Nursing is the Executive Sponsor for the PRMs program at WNSWLHD. They are supported by the Manager of Patient and Carer Experience and Living Well Together.
These sponsors are vital to support the ongoing implementation, scale and spread of PRMs and they champion PRMs at an organisational level. Senior leaders, including service delivery leads, provide strategic support from a local health district perspective. Locally, department heads and clinical program managers provide support from an operations perspective.
In the HFC, the Nurse Practitioner reports to the Deputy Director of Nursing, who informs the Director of Nursing, who informs the Executive Director of Service Delivery.
Champions: These staff members promote and advocate for the adoption of PRMs in their teams and services. In the HFC, they include clinical nurse consultants and other nursing staff. The champions bring colleagues together throughout the implementation process and support the long-term sustainability of PRMs.
Agents: These are the WNSWLHD PRMs Program Leads. They sit in the Quality, Clinical Safety and Nursing Directorate and report directly to the Patient and Carer Experience and Living Well Together Manager. They ensure seamless communication and integration with the LHD’s wider patient safety and quality activity programs.
Alignment of the PRMs Program with the clinical governance units at WNSWLHD is fundamental to healthcare safety and quality. This ensures clinical teams and services are supported to deliver patient-centred care that is responsive to patient preferences and values, using PRMs to guide clinical decision making.
Governance
Local governance is a key driver in the collection of PRMs in the Dubbo Health Service. It is built on local processes for reporting, service improvement and service recovery. PRMs results inform quality and safety meetings, and reporting on chronic care management. All facility-based information feeds into site and sector reporting.
Information collected from PRMs is reported to the Healthcare Quality Committee. This informs service improvement and service recovery activities.
Ad hoc reporting to clinical streams, divisions and networks further enhances governance processes.
Acknowledgements
We acknowledge and thank the following people for their contributions to this project:
- Michelle Baird, Chronic and Complex Care – Nurse Practitioner
- Andrew Muldoon, PRMs Program Lead
- John Gregory, PRMs Program Lead
- Gill Hartas, Agency for Clinical Innovation PRMs Project Officer