Enabling community management of patients with heart failure: the impact of a specialist nurse-facilitated shared-care model

Background

Heart failure (HF) is more prevalent in Asian than Western populations¹. Asian patients present 10 years younger than their Western counterparts, experience poorer quality of life and have worse outcomes¹,². These patients experience frequent emergency department (ED) visits and hospital admissions, contributing to the escalating burden on healthcare costs. Fragmented transitions from hospital to community contribute to HF decompensation and avoidable admissions, compounded by limited robust community-based HF management systems. To address this, we developed a HF specialist nurse–facilitated shared-care model between the HF specialist and community nursing teams.

Methods

From February 2024 to October 2025, a HF specialist nurse collaborated with HF physicians and community nursing teams to provide individualized home-based care to patients living within 2 catchment areas. The program comprised of: (1) joint decision-making on suitability for community-based care; (2) structured training for community nurses (CMN) in HF management, with developed protocols covering comprehensive HF assessment, diuretic titration and escalation criteria; (3) real-time access to HF specialists for complex congestion management; and (4) a tiered follow-up plan. Outcomes evaluated included HF-related hospital readmissions, ED visits, escalation timeliness, and self-reported confidence of CMN.

Results

Of 106 HF patients identified as suitable for community management, with enrolment facilitated by the HF specialist nurse; 87 were successfully enrolled (58% aged ≥70 years, 67% with ≥2 comorbidities). Compared with six months prior to enrolment, HF-related hospital readmissions and ED visits decreased by 69% and 61%, respectively, demonstrating significant cost savings and improved outcomes. Although outpatient cardiology visits increased by 29%, patients benefitted from early intervention and reduced deterioration that may have otherwise necessitated inpatient care. CMN reported increased competence and confidence in implementing earlier, protocol-driven interventions through efficient HF team coordination. Bimonthly multidisciplinary meetings involving HF specialists and primary care physicians facilitated personalized and holistic care of more complex patients.

Real-time consultation with the HF specialist nurse prevented 12 potential ED attendances, further reducing unnecessary healthcare expenditure. No adverse safety events were recorded.

Conclusion

A HF specialty nurse–facilitated shared-care model strengthened community care capabilities, reduced acute healthcare utilisation, and improved continuity of care. This approach demonstrates the pivotal role of HF nurses in bridging hospital-based specialist care and community service, enabling safer, more effective and economically sustainable HF management at home. This model supports value-based care principles and is scalable for broader HF integrated-care strategies.