Cardiology in Community

Cardiology in Community (CIC) is designed to deliver integrated and coordinated cardiology care in the general practice setting, with appropriate access to, and support from, other health care providers.

Patients identified to be at-risk or diagnosed with cardiovascular disease will be directed towards appropriate care and treatment in line with standard care practices. Where atrial fibrillation is detected, patients will be directed towards the enhanced ongoing management and escalation pathway as defined by the Cardiology in Community pathway design.

1. Early intervention: Early intervention through proactive patient screening is a key component of this pathway design. With the aim to reach a larger population of at-risk patients earlier, the design suggests a two-pronged approach to screening. This includes:
   • Opportunistic screening undertaken by Healthcare Neighbourhoods (HCN) and care providers
   • Targeted screening carried out by Patient Centred Medical Home (PCMH) practices
2. Ongoing management and escalation: This pathway is designed around the PCMH and its associated HCN, and outlines how the PCMH will deliver ongoing management and care to a patient who has been diagnosed with atrial fibrillation, with support from the HCN.This seeks to optimise ongoing management delivered through:
   • Enhanced ongoing monitoring of patients diagnosed with atrial fibrillation
   • Integrated shared care planning
   • An improved coordination of care
   In line with standard practice, treatment and ongoing management, plans for different patient types will continue to be defined in HealthPathways. This design will encourage a dynamic relationship between the PCMH, its associated HCN and specialist services, which will result in coordinated and timely care.
3. Handover of care from acute services: This pathway design focuses on the importance of connecting patients back to the general practice care setting, particularly after discharge from hospital services. This is achieved through:
   • Enhanced discharge planning and increased support post-discharge
   • Transition back to care in a general practice setting

Cardiology in Community targets patients in Western Sydney that are at risk of cardiovascular disease. This will include patients with lifestyle factors that could increase the likelihood of disease.

Expected benefits of the Cardiology in Community pathway for your patients are numerous. Early intervention is key for addressing cardiovascular issues and preventing chronic illnesses and complications.

Studies have shown benefits to your patients and the health care system such as:

• Reduction of strokes that are associated with atrial fibrillation through early intervention
• Reduction in emergency department (ED) presentations and hospital admissions for patients exhibiting chest pain symptoms
• Reduction in unnecessary referrals for specialised cardiology care
• Reduction in hospital readmission rates for atrial fibrillation and heart failure patients

As a GP of a patient in the Cardiology in Community program you will also benefit due to the greater connectivity and ease of referral to specialist services. You will be part of a team engaged in comprehensive, streamlined handover of care for enrolled patients who leave hospital or RASS, ensuring that you are kept informed and included in the patients’ care process.

Enrolment in the program will be streamlined through existing software within your practice. The Cardiology in Community team will provide more information on this as they discuss the rollout of the program with you and your staff.

The length of your patients’ participation in the Cardiology in Community program will depend on their specific rick factors and/or medical conditions. Participation remains a discussion between yourself and the patient to ensure that you are both comfortable with the outcomes of the program. Participation is voluntary, so your patient can withdraw at any time.

Patients will not have to do anything greatly different whilst under the Cardiology in Community program. Any support required for facilitating and using items such as remote monitoring devices will be coordinated by the care facilitator.

Any support required for your patients will be provided by the care facilitators by care coordinating and care navigating the support they require in the community.

As the clinician overseeing care for your patient, you will have access to remote monitoring devices that can be used to monitor your patient’s condition. You will also have improved accessibility to specialist and Rapid Access and Stabilisation Services (RASS) support creating collaboration to prevent hospital admissions where possible.

Once your patient has finished the Cardiology in Community program, ongoing care for your patient will continue as usual, with you monitoring for cardiovascular risk regularly as per guidelines. The care facilitator will ensure that any outstanding referrals are communicated with client and service providers to be actioned, and you and your patient may be asked to complete a short survey about the program.

Based on 2020 population data, there are 365,593 people living in Western Sydney with risk factors that could be broadly targeted via early intervention initiatives for cardiology care as part of this program. Of this target population, patients at-risk of atrial fibrillation (aged 65 and above) equates to a target cohort of 130,298. It is estimated that there are currently 2,800 patients in Western Sydney that have been diagnosed with atrial fibrillation or with chest pain symptoms that could benefit from the Cardiology in Community program right now using the remote monitoring devices. Read more about the Cardiology in Community program.