August 2019

Project Name: The Development of an Integrated Heart Failure (“HF”) Service

Joint Working Project Summary: 

This joint working project will involve the extension of the current hospital-based specialist HF service through the deployment of an “in-reach” nurse with the purpose of identifying and triaging HF patients (both at acute medical receiving units and non-Cardiology departments) so they can be appropriately referred to the relevant Cardiology service and receive specialist HF input and subsequently coordinating the discharge of patients and liaising with community teams, including primary care, to ensure continuous appropriate care for HF patients after their discharge from hospital.

In addition, the project will implement a Multi-Disciplinary Team (“MDT”) care for HF patients delivered by HF Consultants, HF nurse specialists, Pharmacists, and, where appropriate Physiotherapist, Palliative Care specialist, Psychologist, Occupational Therapist and/or Administrators. The MDT will review and deliver integrated patient care which may include interventions such as clinical review, medicines management, cardiac rehabilitation, education, self-monitoring and management, telemonitoring or telephone support for the HF patients identified described above.

Expected Patient Outcomes for this Project: 

The following measures will be evaluated by the Trust:

• Development of an in-patient strategy/protocol and implementation procedures of the same to govern the clinical operations of the HF Service
• Positive increase against the following baseline percentage measures as stated in either the Trust audit data or the most up to date NICOR HF audit (whether published or not) for each of the hospitals at Imperial College Healthcare Trust:

• • Percentage of patients receiving HF specialist input
  • Percentage of HF patients who received discharge planning
• • Percentage of HF patients receiving a HFSN follow up appointment within 2 weeks upon discharge
  • Percentage of patients receiving cardiac imaging within 48hrs of admission
  • Readmission rates within 28 days of dischargeIncrease the proportion of patients with LVSD

• Increase the proportion of patients with LVSD receiving guideline-directed pharmacological therapies to 100% excluding those with contraindication or intolerance
• Adherence to local pathway/protocol developed as part of the measures of success described above in the first bullet point
• Patient satisfaction linked to the HF Service (PREMS)

Start Date and Duration: September 2019, 24 months