Our program is designed around you – to provide comprehensive, continuous, and personalized care throughout your heart failure journey. Here, we outline the different teams you may encounter, each playing a crucial role in your care based on your individual needs.

The Heart Failure Spoke

Your journey typically starts with the Heart Failure Spoke, where your primary care provider, be it a Family Doctor or Nurse Practitioner, is the central pillar of your healthcare. They may collaborate with a tailored team of healthcare providers specializing in heart function to enhance your care:

  • Dietitian: Offers guidance on diet, including managing salt and fluid intake and controlling weight.
  • Pharmacist: Assists with medication management, ensuring you receive the most effective combinations.
  • Best Care Therapist: A specialized therapist with extended training in heart failure to educate and co-develop your personalized treatment plan.
  • Nurse Practitioner: Brings advanced skills in diagnosis and treatment, often with specialized training in heart failure management.

Please be aware that the composition of on-site teams can vary between family doctors. Support from specialized healthcare providers remains available for patients whose primary care providers do not have an extended on-site team or those without a family doctor.

The Heart Failure Hub

When more specialized care is needed beyond what the Spoke can provide, your care escalates to the Heart Failure Hub. This team consists of specialists with advanced training in heart function:

  • Nurse Practitioner: Focuses on advanced heart failure management and patient care.
  • Internal Medicine Doctor: Offers expanded expertise in cardiology, supporting complex care needs.
  • Best Care Therapist: Continues to provide specialized heart failure therapy and support.

The Heart Failure Node

The Heart Failure Node steps in for advanced investigations and management that are not available locally. This team includes:

  • Cardiologists: With sub-specialized training, offering advanced diagnostic and treatment options.

Community Paramedics

A unique aspect of our program is that community Paramedics are equipped with specialized skills in heart function care and can provide support directly in your home, bridging the gap between traditional medical care and home-based support.

Telehomecare

Our Telehomecare team, composed of dedicated nurses, utilizes phone and virtual follow-ups to monitor your condition, provide education, and support self-management, all from the comfort of your home.

Home and Community Care, Support Services

This multifaceted team supports your care outside the traditional healthcare settings, potentially including:

  • Nurses and Personal Support Workers (PSWs)
  • Physiotherapists
  • Occupational Therapists
  • Dietitians

Each team member is dedicated to providing the support and care you need to manage your heart failure effectively. Remember, not all patients will require every team member listed, but we are prepared to support you with a comprehensive, integrated approach whenever needed.

By understanding the roles of each part of your care team, we hope to provide a clearer picture of how the Spoke-Hub-Node Program is designed to offer you continuous, tailored, and effective heart failure management.