Table 6 Medly uganda remote clinic design requirements

1. Priority of heart health minimized: Lack of sensitization on heart health and disease management due to focus on HIV and family income generation. Community often views diagnosis of heart condition as helpless

The program will include source of education within community regarding:

1. heart health and wellness

2. common heart HF symptoms and

3. pathways to obtain care or investigation for HF symptoms both at lower health centres and specialized cardiac clinics

Avenues for education include: Radio talk shows, community support groups, knowledge keepers, church events, clinic visits

2. Clinic workflow overwhelmed due to limited staff and resources: Clinicians and VHTs report that limited staff, infrastructure and equipment cause disruption in workflow and patient care experience. High frequency of patients often leads to long wait times and shorter clinician-patient interactions

The program will play a role in reducing the clinic workflow burden by empowering patient self-care in the remote home setting, and subsequently reducing the number of unnecessary and/or emergent patient visits to the clinic

3. Lack of care continuity and relationship building: Patients initial clinic visit often occurs when hospitalized or patient is in HF. Frequency of care touchpoints vary from monthly to every 6-months. However, large disconnect between visits reported, as patients have either given up on improving their condition or are fearful to express state of well-being

The program will provide continuous feedback to ensure level of care continuity is maintained throughout patient’s care journey. Feedback should reflect patient’s individual condition in relation to their reported symptoms

4. Lack of specialist expertise available: Nurse-led clinic, cardiologist rarely available and connection to Uganda Heart Institute (UHI) mainly occurs for patient referrals or transfers. From patient’s perspective, burden of travel to UHI often does not outweigh benefits. From clinician perspective, Medly Uganda system currently would only benefit patients able to travel to UHI to obtain HF diagnosis

The program will facilitate collaborative connection between cardiac clinic and UHI to provide more streamlined care support via:

1. UHI-led cardiac training will be provided to local clinic personnel to allow for growth and capacity development

2. UHI will provide in-person cardiologist or cardiac fellow visit every 3–5 months for mass screening events

3. Medly Uganda dashboard will be adapted to include multiple clinician and admin roles (i.e., Gulu/Lira nurse, UHI cardiologist) across different sites, as source of communication and patient review

5. VHTs undervalued & underutilized: VHTs often serve as the initial touchpoint in patients’ care journey. VHTs also provide frequent care follow-ups within the community, but they are not viewed as part of care team due to their limited knowledge on cardiac care and HF symptoms

The program will facilitate a collaborative workflow amongst clinicians and VHTs to improve the patient’s care experience via:

1. Recognized position within program

2. Direct communication channel with clinic nurse

3. Clinic-led training on heart health, HF symptoms and self-care practices, to allow for more informed patient visits

4. Structured patient follow-up guide created in collaboration with VHTs to guide VHT- patient interactions within the community

6. Financial constraints limit ability to seek care: Patients not motivated to self-care due to financial difficulties, as cost of medication and transport reported as largest barriers to disease management

The program will be free for patients to use. Active self-care promoted by the system will also reduce the financial burden of travelling long distances to obtain clinical support