Congestive Heart
Failure Program

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What is the Heart Failure Program?

The Heart Failure Program brings together primary care providers, hospitals, and other healthcare providers to improve care for people with congestive heart failure (CHF). The program help them live healthier lives by giving them access to the right care and support, both in the hospital and in the community.

Congestive heart failure, or simply heart failure, is when the heart can’t pump blood as well as it should. This can lead to shortness of breath, tiredness, and other symptoms. Left untreated, heart failure can lead to serious health problems, or even death. By working together, we can help people manage heart failure, reduce their symptoms, and improve their quality of life.

How the Program Works

  1. Identifying Patients
    People with heart failure are identified through their primary care providers, hospital visits, or emergency room visits. They are referred to the Heart Failure Program for extra support and care.

  2. Creating a Care Plan
    Once a person is referred, the Integrated Care Lead (a healthcare professional) works with the patient to create a personalized care plan. This plan may include treatments, medications, and lifestyle changes to help manage heart failure. One of the unique aspects of this program consists of remote patient monitoring leveraging digital solutions and devices to measure blood pressure, heart rate, weight. Individuals who are appropriate for the program are monitored in the comfort of their own home and provide daily updates to the nurse who is monitoring their care. This allows for a nurse to provide almost real-time support and monitoring to assist with the individuals’ heart health other care needs.

  3. Getting the Right Care
    Patients are supported by a team of specialists, including doctors, nurses, and other healthcare providers. The team helps patients with everything from medical care to advice on healthy living, like diet and exercise.

  4. Tracking Progress
    Patients’ health is monitored over time, and their care plan is adjusted as needed. Patient-Reported Outcome Measures (PROMs) are used to track how well patients are doing and to make sure they are getting the right care.

  5. Ongoing Support
    The Integrated Care Lead stays in contact with the patient, making sure they get the follow-up care they need. This includes visits to specialists, managing medications, and helping patients stay on track with their treatment plan.

  6. Returning to Regular Care
    Once the patient is stable, the care lead helps transition them back to their regular doctor or connects them with a new healthcare provider if needed.

Who Can Join the Program?

This program is for people who:

  • Have been diagnosed with heart failure

  • Need extra support managing their condition

  • Are living in the MWT-OHT area

  • Are referred by a healthcare provider, hospital, or community clinic

  • Are referred by a healthcare provider to UHN, Sinai or Women’s College cardiology clinic

How to Join

If you or a loved one have heart failure and need help, a primary care or healthcare provider can refer you to the Heart Failure Program. Once referred, you’ll work with a care team to create a plan that’s right for you.

Benefits of the Program

  • Helps manage heart failure and reduce symptoms

  • Provides access to a team of healthcare providers working together

  • Offers support to help you live a healthier life, including advice on diet and exercise

  • Focuses on helping people in the community and reducing hospital visits

The Congestive Heart Failure Program is a proud initiative of the Mid-West Toronto Ontario Health Team, in partnership with University Health Network, Sinai Health, Women’s College Hospital, Parkdale Queen West CHC, Unison Health & Community Services, Centre Francophone du Grand Toronto, SCOPE.