Heart failure follow-up calls: a protocol for Australian GPs

Current Australian guidance treats the first week after a heart failure hospital admission as the highest-risk window for readmission and death, and points to GP review within about seven days of discharge, where possible. A structured follow-up call in that window — covering symptoms, weight, and medication — is how a clinic actually delivers on that guidance, provided every finding gets routed back to the GP or cardiologist rather than acted on by whoever is holding the phone.

Why the first week after discharge carries most of the risk

Heart failure already affects roughly one in 200 adult Australians, according to RACGP’s Australian Journal of General Practice, and close to 144,000 people live with a diagnosis nationally, per the Heart Foundation’s key statistics, which draws on Australian Bureau of Statistics survey data. Hospitalisation is common and recurring: around 170 people are admitted for heart failure every day across the country, based on Australian Institute of Health and Welfare hospital morbidity data cited on that same page.

What matters operationally is what happens after the person leaves hospital. The CATAG practice tool on guideline-directed heart failure therapy, produced through Medicines Advice Initiative Australia with state and territory medicines advisory committees, states plainly that “the most vulnerable period for heart failure readmission and death is the 30 days following hospital discharge.” Its figures make the case for treating that month as a distinct clinical priority, not a quiet gap between the discharge summary and the next routine visit.

Four-year mortality is also split by the type of heart failure: RACGP reports 41% for heart failure with reduced ejection fraction and 32% for heart failure with preserved ejection fraction. Neither number moves on its own — both are shaped by whether the person’s medication and symptoms are actually reviewed in the weeks after they go home, not just diagnosed correctly in hospital.

Australian guidance calls for GP review within about a week

The current Australian clinical guideline for heart failure is the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand’s 2018 guideline, which explicitly includes “telephone support, nurse-led chronic disease management programs, exercise and cardiac rehabilitation” as part of best-practice care. Building on that framework, the 2025 CATAG practice tool is direct about timing: hospital discharge summaries should communicate “the need for GP review within 7 days post-discharge, where possible,” alongside the person’s ejection fraction or heart failure classification, the plan for medication titration, and who on the care team is responsible for what.

That recommendation assumes a GP practice that is ready to receive it — and in practice, many are the default safety net whether or not a formal program exists. An RACGP analysis of national data on chronic heart failure management found that only 26.6% of hospitalised patients were known to be discharged into a structured community-based heart failure program, and that “most patients with heart failure are managed in conjunction with a cardiologist” rather than a dedicated multidisciplinary service. For most people, that leaves the ordinary GP clinic — not a specialist heart failure clinic — as the place where the seven-day review is supposed to happen.

A phone call is often the only realistic way to hit that window. Getting a person who was just discharged, possibly still fatigued or short of breath, physically back into a waiting room within a week is not always practical — particularly outside metropolitan areas. Many GP phone reviews can be bulk billed under the Australian Medicare Benefits Schedule (MBS), which removes cost as a reason to delay the call. The point of the call is not to replace the in-person review the guideline still expects; it is to confirm, early, that nothing has gone wrong while that visit is being arranged.

A structured call has fixed checkpoints, not a free-form chat

An outbound heart failure follow-up call drifts into a vague wellness chat if it is not built around a fixed script. The checkpoints below reflect what the guidance above actually asks a clinic to check in the first week — nothing more, and nothing that requires a clinical decision on the call itself.

1. 1
   Confirm identity, admission, and consent

   Name the clinic, confirm the recent hospital stay for heart failure, and confirm the person is comfortable with a structured follow-up call under the practice's usual privacy process.

2. 2
   Ask about symptoms since discharge

   Breathlessness at rest or on exertion, needing more pillows to sleep, swelling in the ankles or abdomen, and any change in energy or appetite — in the person's own words, not a yes/no checklist.

3. 3
   Check the weight trend

   Ask whether the person has been weighing themselves daily as advised at discharge, and whether weight has moved outside the threshold set in their individual sick-day plan.

4. 4
   Check medication status, not medication judgement

   Confirm which heart failure medicines were started or changed in hospital, whether they have been able to fill and take them, and whether they have noticed dizziness, light-headedness, or swelling — without adjusting any dose on the call.

5. 5
   Close with a concrete next step

   Confirm the already-booked GP review date, book one on the spot if none exists, or escalate the same day if any answer meets the clinic's escalation criteria.

Not every answer needs the same response

A follow-up call only works if the person taking it — a nurse, a care coordinator, reception staff trained for the role, or a structured contact process supporting them — knows in advance what each answer should trigger, agreed with the GP or cardiologist before the first call goes out, not improvised mid-call. RACGP’s 2022 review of heart failure management describes exactly this kind of pre-agreed action plan: the person is advised to “take a short course of increased oral frusemide or seek early GP review in the event of increasing dyspnoea, weight or peripheral oedema.” The call’s job is to check the person’s answers against that plan, not to write a new one.

The two ends of that ladder are the ones worth naming clearly for staff running the calls. At the routine end, most calls simply confirm the plan is on track and the already-booked review still stands. At the other end, RACGP is specific about where a GP hands off to a cardiologist rather than adjusting things independently: starting advanced therapies such as ivabradine or an angiotensin receptor–neprilysin inhibitor, managing significant kidney impairment (stage 4 or 5 chronic kidney disease, which typically needs a nephrologist too), or any suspected angioedema, which means stopping the relevant medicine and seeking cardiologist advice immediately. Titrating standard guideline-directed therapy, by contrast, is “best achieved in cooperation between the cardiologist and the GP” — a shared, ongoing task rather than a one-off escalation.

Where the call routes matters more than who makes it

None of this changes if a clinic scales up how many of these calls it can make. A structured contact process — whether that is a rostered team member working through a list, a nurse-led titration clinic, or a system that helps a clinic reach more people in the seven-day window without dropping any of them — is only ever collecting the same five checkpoints against a plan the GP or cardiologist already set. It does not diagnose deterioration, does not decide a dose, and does not replace the clinical review the person is waiting for; it exists to make sure that review happens on time and that anything unusual reaches a clinician the same day, not at the next routine visit.

This is a narrower problem than the recall cadence a GP Chronic Condition Management Plan runs on — that structure governs how often a plan gets reviewed under Medicare items over months, while a heart failure follow-up call is a clinically specific, short-window check tied to a hospital discharge, not a billing cycle. The two can share the same operational muscle, though: the same discipline that keeps a GP reminder stack from silently dropping patients applies just as well to a seven-day heart failure call list, because both fail the same way — quietly, when nobody owns the follow-up.

What a clinic can set up this week

A clinic does not need a dedicated heart failure service to run this well — it needs one person accountable for the list, a fixed script, and an escalation path everyone agrees on before the phone rings. If your clinic already runs structured access and follow-up more broadly, the Australia practice overview is a reasonable place to see how that kind of contact discipline fits alongside everything else a busy week asks of a GP practice.