Project Name: Service improvement for the detection and treatment of Heart Failure (“HF”) in secondary care
Joint Working Project Summary:
The aim of the proposed JWP is to improve identification, monitoring, management and treatment of HF patients in secondary care via:
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 and receive specialist HF input;
the utilisation of a bespoke HF patient database (the “Database”):the Database will facilitate the identification of new HF patients and the management of existing HF patients in secondary care;
the implementation of a Multi-Disciplinary Team (“MDT”); and
the increase of capacity of the current out-patient HF Specialist Clinic.
The activity of the ‘in-reach’ nurse, the proactive review of the Database by HF specialist nurses (the “HFSN”) and scrutiny by the MDT of the most complex cases will promote timely and appropriate follow-up care, which may include attendance at additional outpatient HF Specialist Clinic, based in secondary care.
Expected Patient Outcomes for this Project:
Targets for measurement and expected outcomes:
increase identification of patients with HF and increase numbers of HF patients receiving specialist input (positive increases against baseline provided by NICOR measures);
increase number of HF patients receiving follow up from median of 8.7 weeks to 2 weeks;
1040 additional encounters with/visits of HF patients in the additional HF Specialist Clinics;
improvement in data collected in relation to HF patients sub-optimally treated in secondary care: measurement will be change from baseline (using NICOR) and comparison to national average; and
optimisation of HF medication in patients sub-optimally treated across secondary care departments leading to increase in the number of HF patients receiving guideline-directed medical therapy (baseline provided by NICOR measures).