Integrated Outpatient Care in Advanced Heart Failure: the Beehive Person-Centered Model

Abstract

Rationale: Cardiovascular disease (CVD) is one of the leading causes of chronic care needs. According to the World Health Organization, by 2030 the number of people dying from CVD is expected to reach 23.3 million. Heart failure is a chronic, progressive, incurable condition which poses a substantial physical, psychological, spiritual and social burden on patients, families as well as formal and informal carers. The complex needs of these patients require the planning and implementation of a new, revisited approach to disease management. Methods: In Trieste, Italy, the long-standing integrated outpatient approach to care has been recently integrated by a dedicated Advanced Heart Failure Clinic (AHFC) for the identification of holistic needs and the provision of multidisciplinary, multidimensional supportive and palliative care to patients with advanced HF and their families. Emphasis is being laid not only on the diseased care recipient but on the ‘person’ who attends and is being attended to, who empowers and is being empowered by through an integrated process of care.Results: The integration of outpatient care services is challenging for all the stakeholders involved. A multidisciplinary, multidimensional, person-centered integrated model of care (the beehive person-centered model) might improve heart failure awareness and knowledge and would help structure better territorial outpatient pathways for patients and families, while enhancing formal and informal carers’ individual roles and general wellbeing.Discussion: The need for interconnectedness in the Beehive Person-Centered Model requires for all stakeholders to view each other as symmetrical allies, which may be utopist at best. Flexibility to adapt to individual, organizational and environmental changes may pose challenges to the long-term sustainability of integrated pathways and bring about conforming behaviors rather than proactive ones, which may jeopardize individual accountability. However, an empowered team may provide short and long term benefits to its members such as clarity of vision, greater self-awareness, self-monitoring and adapatability to changes. Conclusions: A Beehive Person-Centered Model of integrated, multidisciplinary and multidimensional evidence and values-based care may prove useful to reconcile clinical, emotional, spiritual and social needs of all stakeholders involved in the cure/care process and ensure sustainable, efficient and effective long-term care.  Further qualitative/quantitative research is needed to confirm its efficacy and effectiveness and cultural transferability.