Heart failure patients across the continuum of acute inpatient, post-discharge, home program and outpatient follow-up
Heart failure is critical and debilitating with high re-hospitalization rate and 5-year mortality up to 50%. Established in 2008, Keelung CGMH Heart Failure Care Center integrates multidisciplinary teams (cardiology, rehab, family medicine, pharmacy, nutrition, social work) into a seamless care continuum from hospitalization, post-discharge, home program, outpatient clinic to cardiac rehabilitation. The center significantly lowered re-admission rate, mortality and medical expenses, earning the JCT Gold Award (2012) and SNQ recognition since 2018. It hosted the Asia-Pacific International Heart Failure Care Conferences (2014, 2018), welcomed visits from 22 institutions and delivered 12 invited lectures, becoming a promoter of long-term heart failure care worldwide.
First multidisciplinary integrated heart failure team in Taiwan (physicians, nurses, dietitians, rehab, PT, pharmacists, social workers). 2. 24-hour wireless physiological monitoring system detecting high-risk arrhythmia. 3. First in Taiwan to provide combined heart failure clinics (cardiologist + case manager + dietitian + pharmacist concurrently). 4. Innovative use of advanced body composition analyzer to establish objective edema index. 5. Dedicated cardiopulmonary testing and rehabilitation area in glass house design within the cardiology ward. 6. Co-founded the Keelung Heart Health Association (2018), Taiwan's first government-registered heart failure patient group.
The Heart Failure outpatient clinic serves an average of approximately 6,627 patient visits annually.
From 2017 to 2020, the average annual number of hospitalized patients was 139.
The Heart Failure Center organized 8 patient education and support activities, with a total attendance of 442 participants and a satisfaction rate of 92.0%.
The heart failure readmission rate was only 0.9% within 94 days, outperforming reported rates in the United States of 20% within 30 days and 50% within 180 days.
The heart failure readmission rate was only 0.9% within 94 days, outperforming reported rates in the United States of 20% within 30 days and 50% within 180 days.
The mortality rate among heart failure patients was lower than those reported in the United States (20–30% within one year and 45–60% within five years) and Europe (11% within one year and 41% within five years).
Three-Tier Safeguards for Heart Failure Guideline-Directed Medical Therapy (GDMT) (1) Clinical pathway reminders achieved 100% compliance. (2) Physicians must document reasons for non-use of standard medications before discharge prescriptions can be issued, achieving 100% compliance. (3) Medication use is audited through the case management system to improve GDMT adherence.
High Utilization of Standard Heart Failure Medications (1) Beta-Blockers/Ivabradine: 90-day post-discharge utilization rate of 93.8%–100% (2015–2019). (2) ACEI/ARB/Entresto: 90-day post-discharge utilization rate of 96.9%–100% (2015–2019).
Patient satisfaction surveys conducted before discharge assessed five domains—environment, clinical care, health education, team performance, and overall service quality—with an average satisfaction rate of 96.6% in 2019.
Quality of life, measured by the EQ-5D across five domains—mobility, self-care, usual activities, pain/discomfort, and anxiety/depression—showed significant improvement one year after discharge.
JCT Gold Award (2012); SNQ National Quality Mark consecutively from 2018-2020; Case Manager Min-Hui Liu won 1st place in TSC oral presentation (2019) and served as national trainer for heart failure post-acute care (2017-2020).
