Based on 2020 population data, there are 365,593 people living in Western Sydney with risk factors that could be broadly targeted via early intervention initiatives for cardiology care as part of this program. Of this target population, patients at-risk of atrial fibrillation (AF) (aged 65 and above) equates to a target cohort of 130,298. It is estimated that there are 2,800 patients in Western Sydney that have been diagnosed with AF or with chest pain symptoms that could benefit from the Cardiology in Community (CIC) program[1].
The CIC program is part of the Western Sydney Care Collective initiative, a partnership between Western Sydney Primary Health Network, operated by WentWest, and Western Sydney Local Health District, to deliver a whole of system approach to transform health care in Western Sydney.
Designed to deliver integrated and coordinated care within a primary health setting, the CIC program provides eligible patients with access to general practice, specialists, pharmacists, and health care tools to help deliver coordinated, timely cardiology care.
CIC supports patients in Western Sydney aged 45 years and over who have hypertension, diabetes, obesity, sleep apnea, smoking, alcohol consumption and stroke that could increase their likelihood of developing AF. The length of a patient’s participation in the program will depend on their specific risk factors and medical conditions. Participation is voluntary and remains a discussion between clinicians and the patient to ensure that they are comfortable with the outcomes of the program. Under CIC, patients and the clinicians overseeing them will have access to resources such as remote monitoring devices which are coordinated by a care facilitator and used to monitor the patient’s condition.
The pathway design aims to:
- Strengthen participation and screening to improve identification of people at risk of cardiovascular disease, in turn supporting management of heart failure, chest pain and AF
- Enhance the ongoing management and treatment of patients with AF
- Improve access to the Rapid Access and Stabilisation Services and enhance stabilisation of patients
- Upskill general practice and enhance capacity for cardiology management
- Reduce the volume of avoidable emergency department (ED) presentations
Key Stages
The three key stages of CIC are:
- Early intervention
- Ongoing management and escalation
- Handover of care from the discharge team at ED/hospital to an ongoing care team
The first stage covers a broader range of cardiovascular diseases than the other two stages, which focus specifically on AF. Patients identified to be at-risk or diagnosed with cardiovascular disease will be directed towards appropriate care and treatment in line with standard care practices. Where AF is detected, patients will be directed towards the enhanced ongoing management and escalation pathway as defined by this CIC pathway design.
Cardiology Resources to Support Your Practice
GoShare Bundles
GoShare is a free patient education platform that allows general practice to share tailored and latest resources with patients such as videos and factsheets. There are specific CIC GoShare bundles and an interactive AF module that can help increase health literacy and enhance patient awareness and engagement.
Western Sydney HealthPathways
Health professionals can find the latest cardiology clinical topics, protocols and localised referral services through the Cardiology pathway on the Western Sydney HealthPathways platform.
If you require the log in details to access HealthPathways, please contact our HealthPathways team at healthpathways@wentwest.com.au
2 November 2023
[1] Western Sydney Local Health District (2022), Cardiology in Community FAQs for GPs. Accessed by: https://www.wslhd.health.nsw.gov.au/Western-Sydney-Care-Collective/Cardiology-in-Community/gp-faqs