Review of Cardiovascular Disease Programs


Victoria - Appendix D - Jurisdictional Responses - Review of Cardiovascular Disease Programs

Page last updated: 03 May 2012

A number of policies were outlined as being relevant to the critical intervention points, these include:

  1. Cardiac Services Framework for Victoria
    This document is predominantly refers to management of Acute Coronary Syndromes in the acute settings addressing Intervention point 3 "Best care and support for the acute episodes" with the major emphasis on interventional cardiology. There is some mention of cardiac rehabilitation and heart failure and assumes that care will be delivered in the same manner in 10 years time as it is today. The website link for this framework is http: // [Broken link - valid at time of publication]

  2. The Metropolitan Health Strategy
    The aim of this document was to further develop a public health system that provides optimal level, distribution and mix of services to meet growing unchanging demand while ensuring : patient focused; safe , high quality appropriate services: timely access to services and sustainability of service provision and discusses care of the patient along the continuum of care. Doesn't talk about critical intervention point but does discuss general chronic disease management.

  3. Improving care for older people: a policy for health services 2003
    A policy framework for the effective care of older people by health services, which focuses on integrating care across settings to ensure people have the appropriate care in the appropriate place.

  4. From hospital to home: Victoria's Pathways Home program report 2003-2008
    The pathways home program focused on ambulatory care development, specifically home-based and centre-based rehabilitation services, and establishing Centres Promoting Health Independence. The implementation of the plan has enabled treatment and care to be increasingly delivered by health services in ambulatory and community-based settings.

  5. Promoting health independence: a framework for better care
    The Health independence programs framework has been developed to enable a better client journey across the care continuum in transition from hospital to home or preventing hospitalisation.

  6. Health independence programs guidelines
    The Health independence programs guidelines have been developed to provide direction for, and facilitate the alignment of, post-acute care services (PAC), sub-acute ambulatory care services (SACS), and hospital admission risk programs (HARP). Integrated PAC, SACS and HARP guidelines have been developed to enable a better client journey across the care continuum in transition from hospital to home or preventing hospitalisation.

  7. Care in your community: A planning framework for integrated ambulatory health care (2006)
    A policy and planning framework for ongoing development of Victorian health services. The framework encompasses all community-based, ambulatory care services. The vision is for a modern, integrated and person-centred health system aimed to meet the future needs and expectations of communities and individual users of health care services, and to provide integrated and accessible services in local communities.

  8. Advance care planning
    Advance Care Planning (ACP) draft policy to inform, guide and support its implementation across Victoria has been developed, guided by an expert advisory group, and extensive consultation. The policy communicates the broad direction of the Victorian Government for improving access to ACP in health services. The main population focus of the policy is older adults and adults with life threatening and serious chronic and complex illnesses, and their carers - including carers of people who currently lack decision-making capacity. ACP program development is continuing, as is the development of an ACP evaluation framework for health services. Victoria is also represented on the AHMAC CTEPC National Advance Care Planning Working Group that is facilitating a national framework and guidelines for advance care directives and related matters, within the broader context of advance care planning, and to advise on how the guidelines could best be implemented.

  9. Hospital admission risk program (HARP): Chronic heart failure working party report (2003)
    This report provides recommendations for the development of programs that address chronic heart failure that provide opportunities to have a significant impact on preventing the avoidable use of hospitals.

  10. Directions for your health system: Metropolitan Health Strategy (2003)
    A policy and planning framework for providing health care services across metropolitan Melbourne, including an expanded role for ambulatory care services as a cornerstone in the configuration of health care services.

  11. Rural directions for a better state of health (2005)
    A policy and planning framework for developing rural health services in Victoria. Three broad directions have been identified: promote the health and wellbeing of rural Victorians; foster a contemporary health system and models of care for rural Victoria; and strengthen and sustain rural health services.

  12. Early Intervention in Chronic Disease Prevention Initiative
    The Early Intervention in Chronic Disease (EIiCD) Initiative provides care to people with chronic diseases and complex needs who may progress towards requiring hospitalisation in the medium to long term. EIiCD services provide multidisciplinary care including assessment, care planning, selfmanagement support and clinical intervention based on best practice guidelines. The initiative has a focus on working in partnership with the client (and carer) and other providers including general practice to best meet the needs of the client and support behaviour change. The initiative is supported by the Primary Care Partnership strategy.

  13. HARP-CDM ( Chronic Disease Management) Initiative
    Hospital Admission Risk Program–Chronic Disease Management (HARP-CDM) service framework, which provides care to people with chronic diseases or complex needs who are at risk of avoidable hospitalisation. HARP-CDM services provide more appropriate and timely care for people in the community and provide assessment, monitoring, education, self-management, service coordination and a flexible service response through brokerage. The target group for HARP-CDM is people who are at risk of avoidable hospitalisation with chronic respiratory disease, chronic heart failure, complex needs, complex psycho-social needs and complications as a result of diabetes.

  14. Primary Care Partnerships - Strategic directions 2004-07
    The aim of this strategy is to ensure an integrated health care system, based on partnerships, where providers see planning and working together to better meet the needs of their communities. The strategy has a focus on the following four areas partnership, service coordination (incorporates access to appropriate services in a timely manner), integrated health promotion and integrated chronic disease management (focus on systems redesign).

  15. Other reported strategies include:

    1. Revised Chronic Disease Management Program guidelines for Primary Care Partnerships and Primary Health care Services October 2008

    2. Improving care for older people: a policy for health services 2003

    3. Care in your Community

    4. Hospital demand strategy

    5. Review of Adult Emergency Retrieval and Coordination Service Model

    6. Healthy Communities Victoria

    7. The Metropolitan Health Strategy

    8. Rural directions for a better state of health

    9. Statewide emergency program

    10. Outpatient Innovation and Improvement Program

    11. Stroke Care Strategy for Victoria
      http: // [Broken link - valid at time of publication]

The following table provides an overview of the reported programs and strategies.

Table 6. Overview of jurisdictional programs and strategies
Programs / Strategies Overview Critical Intervention Points
Cardiac Clinical Network The establishment of a cardiac clinical network is in it s infancy stages but aims to address the patient journey through the cardiac continuum of care. Currently developing a fully costed Cardiac Services Strategy to build a truly integrated cardiac service to ensure that all Victorians have access to high quality cardiac services. Initially the network will address the care of the patient in the acute episode and referrals to cardiac rehabilitation.
  • Early detection (14,15,16,17)
  • Acute episode (18,20,21,23)
  • Long term (24,27,28)
Renal Health Clinical Network The Renal Health Clinical Network (RHCN) was recently established to provide a new focus across all clinical disciplines towards prevention of illness and injury and maintenance of health, and to bring about an improvement in the delivery of sustainable health services. The RHCN Leadership Group has identified that the development of a Renal Health Strategic Plan for Victoria will be a key priority and the first major piece of work to be undertaken by the clinical network. It is possible that the Renal Health Strategic may identify programs in the relevant critical intervention points highlighted
  • Reduce risks (5)
  • Early detection (7,8,9,10,12)
  • Acute episode(22)
  • Long term (25,26,29)
  • Advanced care (31,32,33,34)
Public Health Social Marketing - The Government has committed $5.622 million dollars (for the three years 2007-2010) to the Quit Social Marketing program. Legislation – the government is currently examining the following legislative amendments to the Tobacco Act 1987 as part of the Victorian Tobacco Control Strategy 2008-2013 (VTCS) through: reform of point-of-sale displays in retail outlets; a ban on smoking in cars carrying children; a ban on smoking on government school grounds; and a ban on the sale of tobacco from temporary vendors.
  • Reduce risks (1)
Public Health The Heart Foundation has been funded $492,471 by the Department for the Go for your life Just Add Fruit & Veg project, which is due for completion in February 2009. Increasing fruit and vegetable consumption is one of the Go for your life objectives with inadequate consumption of contributing to poor health, obesity and a range of chronic diseases.
The Victorian Government through VicHealth fund a project entitled Food for All which aims to promote improved access to nutritious food and ensuring food security in partnership with local government. Eight councils covering nine municipalities are involved.
  • Reduce risks (2)
Public Health The Victorian government recognises that physical activity levels and the eating habits of Victorians are influenced by the surrounding environment. This includes access to local services, shops, workplaces and community facilities as well as walking tracks, transport links, bike paths and sport and recreational facilities including open space.
The 'Environments for Health' policy framework for municipal public health planning developed in 2001 explicitly acknowledges the role of the built and natural environments in influencing health, and over the past several years the Department of Human Services has supported local governments to take up the Heart Foundation's 'Healthy by Design' guidelines. This has included targeted small grants to selected local governments to embed 'Healthy by Design' principles in their local planning activities.
  • Reduce risks (3)
Public Health The 2006-2010 ‘Go for your life’ Strategic Plan’ acknowledges structural changes to the built environment and activity is occurring across government departments to deliver structural changes to support healthy eating and physical activity. For example, the Department of Sustainability and Environment’s East Gippsland ‘Go for your life’ community partnership implements a range of public land projects with a focus on accessibility for all. ‘Go for your life’ also collaborates with the Department of Transport who has committed to a $100 million package of improvements to cycling infrastructure as part of the Victorian Transport Plan recently launched by the Premier. The Department of Planning and Community Development is also progressing a range of initiatives to link planning with community development and build active, confident and inclusive communities
  • Reduce risks (3)
Primary Health Branch The Primary Health branch has endorsed a range of strategies and initiatives that aim to improve the care provided to clients and carers and meet identified needs. These include specific initiatives to address chronic disease (including cardiovascular disease) such as Early Intervention in Chronic Disease services, Aboriginal Health Promotion and Chronic Care Partnerships and Community Health program. Services provided include a range of allied health and nursing services, education, self-management support, exercise and rehabilitation programs and access to (referral) to other services as required.
  • Early detection (14,15,16,17)
  • Acute episode (24,29,30)
Hospital admission risk program (HARP) The HARP commenced in 2001 as a pilot and was rolled out across the state in 2005. There are 22 health services across Victoria with HARP services. HARP services manage people with chronic disease, aged and/or complex needs who frequently use hospitals or are at risk of hospitalisation. The two streams of care provided by HARP are chronic disease (including chronic heart disease) and aged and complex care.
The HARP model of care is described in the Health independence programs guidelines (2008). Specifically for chronic heart disease the HARP model of care includes: All patients with established CHF require:
  • seamless progression through each stage of education, management and support
  • optimal pharmacological management, directed by national and international guidelines
  • non-pharmacological management in the form of an integrated disease management program, supported or managed by a heart failure (nurse) coordinator
  • a continuing program of activity and exercise based upon walking and maintenance of muscle strength for activities of daily living
  • all patients and carers require education and support in achieving and maintaining a program of self care, based on self management principles and includes telephone coaching.
  • Early detection (14,16,17,18)
  • Acute episode (20,22,23)
  • Long term (24,27,28,29,30)
  • Advanced care (31,32,33,34)
Sub-acute ambulatory care services (SACS) Sub-acute ambulatory care services are available to people of all ages and may follow a hospital stay, hospital day attendance, or may be accessed directly from the community. SACS extend and complement inpatient services. SACS can be delivered in a client’s home or at an ambulatory care centre. There are 35 health services that deliver SACS from 53 sites across Victoria.
  • Early detection (14,16,17)
  • Acute episode (18,22)
  • Long term (24,27,28,29,30)
  • Advanced care (31,33,34)
Post acute care (PAC) Post-acute care services aim to assist people discharged from a public hospital, including emergency departments, acute services and sub-acute services, who have been assessed as requiring short-term, community-based supports to assist them to recuperate in the community and to ensure a safe and timely discharge. Admission to PAC is based on an assessment of the person’s need for short-term community-based services and takes into account the person’s health care needs and psychosocial factors that may impact on their capacity to safely recuperate in the community. There are 27 PAC services across the state. The key features of PAC are to:
  • provide a rapid response to referrals for services to facilitate safe and timely discharge from a public hospital
  • purchase and coordinate short-term, community-based services in response to individually assessed needs
  • facilitate referral to longer term service providers where required.
  • Early detection (16)
  • Acute episode (18,22)
  • Long term (24,27,28,29,30)
  • Advanced care (31,32,33,34)
Hospital in the home (HITH) Hospital in the home is the provision of hospital care in the comfort of the persons own home, or other suitable environment. Patients are regarded as hospital inpatients and remain under the care of their treating doctor in the hospital. Patients receive the same treatment that they would have received had they been in an inpatient hospital bed. Patients may be able to receive all their hospital care in HITH or they may have a stay in hospital then receive HITH in the latter part of their treatment. There are 47 participating hospitals who provide HTIH.
  • Acute episode (18, 20, 22)
  • Long term(24,27,29,30)
  • Advanced care (31,32,33,34)
Transition Care Program (TCP) A partnership agreement between the Australian Government and the State and Territory Governments, resulted in the establishment of a national Transition Care Program (TCP) in 2005.
The program complements existing sub-acute services and is designed to help older people leaving hospital return home rather than inappropriately enter residential care. The TCP is time-limited, goal oriented and therapy focused, providing older people with a package of services that includes low intensity therapy (such as physiotherapy, occupational therapy and social work), case management and either nursing support and/or personal care. It helps older people complete their restorative process and optimise their functional capacity, while assisting them and their family or carer to make long-term care arrangements. Victoria has 570 places operational of the 2,228 places currently available nationally. By the end of 2011-12, there will be 4,000 transition care places nationally, of which 1,000 will be operational in Victoria.
  • Early detection (14,16,17)
  • Acute episode (18)
  • Long term (24,25,28,29,30)
  • Advanced care (31,33)
Primary Health Branch The Primary Health branch has endorsed a range of strategies and initiatives that aim to improve the care provided to clients and carers and meet identified needs. These include specific initiatives to address chronic disease (including cardiovascular disease) such as Early Intervention in Chronic Disease services, Aboriginal Health Promotion and Chronic Care Partnerships and Community Health program.
  • Early detection (14,15,16,17)
  • Acute episode
  • Long term (24,29,30)
Stroke Network In 2007 the Victorian Government released the Stroke Care Strategy for Victoria which included28 recommendations. Implementation of this strategy is supported by a commitment of $5 million over three years
  • Reduce risks (2)
  • Early detection (8,9,10,11,13,14,15,16,17)
  • Acute episode (18,19,20,21,22,23)
  • Long term (24,28,29,30)
  • Advanced care (31,32,33,34)

Top of page