An Intervention to improve Primary Care Adherence To Heart Failure guidelines IN Diagnosis, Evaluation & Routine management (PATHFINDER) pilot program

a) Physical or informational materials used: There are two distinct components to the PATHFINDER intervention, i.e. the information/resources provided to the patients and the medication titration plan etc. for GPs. Heart failure (HF) education materials will be given to patients to support self-management ;PATHFINDER study follow up forms (including assessment, medication titration plan, HF helpline, problem solving guide) will be provided to patients’ GPs to support titrating medication to target dose. b) each of the procedures, activities, and/or processes used: HF education to patients upon discharge; patients be referred to cardiac rehabilitation program (an existing program in care system, involving a health care team, a personalised education and exercise program, the program runs 30-50 minute per session, two to three times per week and for 6-10 weeks depending on patients' health condition) ; medication titration support for GP post-discharge with cardiologist support through the Advanced Heart Failure and Cardiac Transplant Service (FSH); The type of support for GPs will be medication titration plan at discharge; HF helpline, unlimited phone calls or video-conferencing for case management. The NP will review the case initially and provide recommendations that are within their scope of practice. For more complex cases and those that are outside their scope of practice they will escalate the case to a cardiologist who will review and provide recommendations. c) who will deliver the intervention: the study HF nurse practitioner (NP) will deliver the heart failure education after enrolment , facilitated cardiac rehabilitation program, and PATHFINDER study follow up forms; HF NP will triage and facilitate medication titration support. GPs will receive the PAHTFINDER study follow up form when patients visit GPs. If the GP needs support, they will contact HF helpline (HF NP )in the first instance, who will either provide advice or escalate to a cardiologist as described at b). (NP helpline has been created specifically for GPs for this study. The aim of NP helpline is to help GPs to manage patients' HF symptoms and patients' heart failure medication if GPs are not confident with HF medication titration or if they have any questions with HF care. NP helpline can be accessed during the study period, Monday to Friday, from 8 am to 4 pm) d) the mode of delivery: face-to-face of heart failure education; via telephone or video conference to support medication titration e) the number of times the intervention will be delivered and over what period of time: HF education 1 session *1 hour; GP/NP interactions will be ad hoc (as needed). f) the location/setting where the intervention occurs: FSH g) any strategies used to assess or monitor adherence or fidelity to the intervention: audit and feedback from patients/GPs