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

Main Article Content

Kira Stellato
Franco Humar
Cristina Montesi
Donatella Radini
Raffaella Antonione
Gianfranco Sinagra
Andrea Di Lenarda


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. 

Article Details

Regular Articles
Author Biography

Kira Stellato, Cardiovascular Center, Health Authority n°1, Friuli-Venezia Giulia and University of Trieste, Italy

Counseling Psychologist Consultant at the Cardiovascular Center Health Authority n°1, Friuli-Venezia Giulia and University of Trieste, Italy and Social Program Coordinator for the EU SmartCare Project


Rich, M.W. (2001). Heart failure in the 21st century: a cardiogeriatric syndrome. Journals of Gerontology: Biological Medicine Sciences, 56(2): M88-96.

World Health Organization. (2011) Global atlas on cardiovascular disease prevention and control. World Health Organization.

Department of Health (2000) National Service Framework for Coronary Heart Disease: Chapter 6. Heart Failure. London. Department of Health.

Beattie, J., Goodlin, S. (2008) Supportive care in heart failure. Oxford: Oxford University Press.

Stewart S., Jenkins A., Buchan S., McGuire A., Capewell S., McMurray J.J.V.(2002) The current cost of heart failure to the National Health Service in the UK. European Journal of Heart Failure, 4, 361-371.

Mosterd, A., Cost, B., Hoes, A., de Bruijne, M.C., Deckers, J.W., Hofman, A., Gobbee, D.E. (2001) The prognosis of heart failure in the general population. European Heart Journal, 22:1318-1327,

Braunstein, J.B., Anderson, G.F., Gerstenblith, G., Weller, W., Niefeld, M., Herbert, R., Wu, A. (2003) Non cardiac comorbidity increases preventable hospitalizations and mortality among medicare beneficiaries with chronic heart failure. Journal of the American College of Cardiology, 42, 1226–1233.

NHS Modernisation Agency. (2004) Coronary heart disease collaborative. Supportive and palliative care for advanced heart failure. London Department of Health, Coronary Heart Disease Collaborative.

Malistar, F.A., Lawson, F.M.E., Teo, K., Armstrong, P.W. (2001) A systematic review of randomized trials of disease management programs in heart failure. The American Journal of Medicine, 5, 378-384.

Braunstein, J.B., Anderson, G.F., Gerstenblith, G., Weller, W., Niefeld, M., Herbert, R., Wu, A.W. (2003) Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure. Journal of the American College of Cardiology, 42, 1226-33.

NHS Modernisation Agency (2004). Coronary heart disease collaborative. Supportive and palliative care for advanced heart failure. London Department of Health: Coronary Heart Disease Collaborative.

National Council for palliative Care (2005) National survey of patient activity data for specialist palliative care services: Full report for the year 2003-2004. NCPC, London.

Saunders, C., Baines, M., Dunlop, R.(1995) Living with Dying: A Guide to Palliative Care. Oxford Medical Publications.

World Health Organization. (2004) Palliative care: the solid facts. Copenhagen: World Health Organization.

Hockley, J.M., Dunlop, R., Davies, R.J. (1988) Survey of distressing symptoms in dying patients and their families in hospital and the response to a symptom control team. British Medical Journal, 296, 1715-1717.

Cohn, J., Rector, T.S. (1988) Prognosis of congestive heart failure and predictors of mortality. American Journal of Cardiology, 62, 25A-30A.

Luttik, M. L., Jaarsma, T., Moser, D., Sanderman, R., van Veldhuisen, D. (2005) The Importance and Impact of Social Support on Outcomes in Patients With Heart Failure: An Overview of the Literature. Journal of Cardiovascular Nursing, 20, 162-169.

Rees, J., O’Boyle, C., MacDonagh, R. Quality of life: impact of chronic illness in the partner. Journal of the Royal Society of Medicine, 94, 563-566.

Fallowfield, L., Jenkins, V. (1993) Effective communication skills are the key to good cancer care. European Journal of Cancer, 35, 1592-1597.

Rogers, A.E., Addington Hall, J.M., Abery, A.J., McCoy, A.S.M., Bulpitt, C., Coats, A.J.S., Gibbs, J.S.R. (2000). Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. British Medical Journal, 321, 605-607.

Strine, T.W., Chapman, D.P., Balluz, L., Mokdad, A. (2008). Health-related quality of life and health behaviors by social and emotional support. Their relevance to psychiatry and medicine. Social Psychiatry and Psychiatric Epidemiology, 43,151-159.

Majani, G. (1999) Introduzione alla psicologia della salute. Milano: Editore Centro Studi Erickson.

Rozanski, A., Blumenthal, J.A., Kaplan, J. (1999) Impact of Psychological factors on the pathogenesis of cardiovascular disease and implications of therapy. Circulation, 99, 2192-2217.

Blazer, D.G., Kessler, R.C., Mc Gonagle, K.A., Schwarz, M.S. (1994) The prevalence and distribution of major depression in a national community sample: the national co-morbidity survey. American Journal of Psychiatry, 151, 979-986.

Player, M.S., Peterson, L.E. (2011) Anxiety disorders, hypertension, and cardiovascular risk: a review. International Journal of Psychiatry Medicine, 41(4), 365-377.

Booth-Kewley, S., Friedman, H.S. (1987) Psychological predictors of heart disease: A quantitative review. Psychological Bulletin, 101, 343-362.

Steptoe, A., Molloy, G.J. Personality and heart disease. Heart, 93(7), 783-784.

Anda, R., Williamson, D., Jones, D., Macera, R., Eaker, E., Glasman, A., Marks, J. (1993) Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of U.S. adults. Epidemiology, 4, 285-294.

Everson, S.A., Goldberg, D.E., Kaplan, G.A., Cohen, R.D., Pukkala, E., Tuomilehto J., Salonen, J.T. (1996) Hopelessness and risk of mortality and incidence of myocardial infarction and cancer. Psychosomatic Medicine, 58, 113-121.

Carneya, R.M., Freedlanda, K.E., Millerb, G.E., Jaffec, A.S. (2002) Depression as a risk factor for cardiac mortality and morbidity: A review of potential mechanisms. Journal of Psychosomatic Research, 53(4), 897-902.

Cramer, A.O.J., Waldorp, L.J., van der Maas, H.L.J., Borsboom, D. (2010) Comorbidity: a network perspective. Behavioral and Brain Sciences, 33, 137-193.

Horste, M., Mittleman, M.A., Wamala, S.P., Schenck-Gustafsson, K., Orth-Gomér, K. (2000) Depressive symptoms and lack of social integration in relation to prognosis of CHD in middle-aged women. European Heart Journal, 21, 1072-1080.

Kasper, E.K., Gerstenblith, E., Hefter, G., Van Anden, E., Brinker, J.A., Thiemann, D.R., Terrin, M., Forman, S., Gottlieb, S.H. (2002) A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. Journal of American College of Cardiology, 39, 471-480.

Scardi, S., Humar, F., Di Lenarda, A., Mazzone, C., Giansante, C., Sinagra, G. (2007) Disease management system in patients with chronic heart failure. Giornale Italiano di Cardiologia, 8, 83-91.

Haley, W., Larson, D., Godley, J., Neimeyer, R., Fwilosz, D. (2003) Roles for psychologists in end-of-life care: emerging models of practice. Professional Psychology: Research and practice, 34, 626-33.

Brown R.T., Freeman, W.S., Brown, R.A., Belar, C., Hersch, L., Hornyak, L.M., Rickel, A., Rozensky, R., Sheridan, E., Reed, G. (2002) The role of psychology in health care delivery. Professional Psychology: Research and Practice, 33, 536-545.

Page, R.E. (2013) The Spirit of the Hive.The Mechanisms of Social Evolution. Harvard College.

Moritz, R. F. A.; Southwick, E. E. (1992) Bees as superorganisms: an evolutionary reality. Berlin: Springer Verlag.

Fisher, R.L., Klinkerborg, V. (2010) Bee. Princeton Architectural press.

Darwin, C. The Origin of Species (1859) Published 1998. Wordsworth Editions Ltd., 978, 780-782.

Goodlin SJ, Hauptman PJ, Arnold R et al. (2004) Consensus statement: palliative and supportive care in advanced heart failure. Journal of Cardiac Failure, 10, 200-209.

Institute of Medicine (US) Committee on Behavioral and Social Sciences in Medical School (2004) Curricula Improving Medical Education: Enhancing the Behavioral and Social Science in Medical School Curricula. Washington (DC): National Academies Press.

Meyer, I., Muller, S., Kubitschker, L. et al. (2013) eCare Benchmarking. Coping with an ageing population – Learning from good eHealth and tele-care practices (SMART 2010/0023).

Murray, S.A., Kendall, M., Boyd, K., Sheikh, A. (2005) Illness trajectories and palliative care. British Medical Journal, 330, 1007-1011.

Pulignano, G., Del Sindaco, D., Di Lenarda, A., Sinagra, G.F. (2006) The evolving care for elderly with heart failure: from the “high tech” to the “high touch” approach. Journal of Cardiovascular Medicine, 7, 841-846.