General practices demonstrate the impact of team-based heart failure care
The Chronic Heart Failure (CHF) Pilot Project showcased the commitment of 16 general practices across Armadale, Swan, Geraldton, the South West and Great Southern in demonstrating how practice-led, multidisciplinary care can make a meaningful difference for people living with CHF.
The project was designed to strengthen the management of CHF in general practice and support practice teams to lead and coordinate evidence-based, multidisciplinary care. Delivered across two project tranches, it brought together the following four core elements:
- Accredited CHF education for GPs, nurses and pharmacists.
- CHF-focused quality improvement activities.
- The integration of non-dispensing pharmacists within practices.
- Stronger coordination between general practice and hospital care.
Participating practices adapted these elements to their local context, identified patients who could benefit, strengthened clinical systems and worked together to provide more planned and coordinated care.
The results of the evaluation
The final evaluation compared patients attending project practices with similar patients attending other general practices. Patients attending project practices:
- Received higher rates of preventive health care, chronic disease management and case conferencing.
- Had lower rates of CHF-related and non-CHF-related GP-type emergency department presentations.
- Had lower rates of non-CHF-related inpatient admissions. Reduced inpatient admissions were associated with estimated hospital cost reduction of $3,000 per person-year.
The evaluation also found that non-dispensing pharmacists strengthened medication reviews, case conferencing and chronic disease management planning. These benefits were enabled by practices making space for multidisciplinary teamwork and embedding the pharmacist within their existing clinical and administrative systems.
The difference made by practice teams
The evaluation results reflect the contribution of the whole practice team:
- GPs provided clinical leadership and continuity of care.
- Practice nurses supported education, monitoring and planned follow-up.
- Practice managers and administrative teams helped establish workflows, coordinated activity and made the model work in busy practice environments.
- Embedded pharmacists added dedicated medication expertise and supported proactive review of patients with complex needs, as well as providing face-to-face patient support and education.
The project also highlighted areas for continued improvement across the broader health system, including more consistent recording of CHF diagnoses, better-quality discharge information and stronger follow-up after hospital care. These are shared system challenges, and the experience of participating practices provides valuable guidance for future models.
Thank you to every participating practice and staff member. By contributing time, expertise, data and honest feedback, practice teams have helped build evidence that well-supported general practice can improve care, help patients remain well in the community and reduce avoidable hospital use.
Acknowledgements
The authors wish to thank the staff at Western Australian Data Linkage Services, the Hospital Morbidity Data Collection and the Emergency Department Data Collection Custodians.
The evaluation was delivered by Curtin School of Population Health, with data linkage supported by the Curtin Centre for Data Linkage and LinXmart.
For any enquiries regarding the CHF Pilot Project Evaluation, contact Dr Christina Read via christina.read@wapha.org.au