Aim

• To provide support and guidance to the patients and their carers in order for them to gain a better understanding and control over their heart condition.

Objectives 

• To provide patients, families and carers with education, advice and support in order for them to become more actively involved with the management and monitoring of their condition.
• To enhance quality of life for heart failure patients by ensuring they receive an individualized patient management plan. This will enable them to play a more active role in the management of their care.
• To routinely monitor patients to identify potential occurrences of a crisis and act accordingly.
• To reduce incidents of unnecessary emergency admissions to hospital and minimizing inappropriate interventions which may impact on their quality of life.
• To promote effective communication between all the members of the multidisciplinary team involved in the patients care pathway.
• To develop and improve palliative care services within the community where appropriate.

• To implement advanced care planning initiatives including preferred place of care and death.

Referrals to programme

Identification of eligible patients

• Primary clinical problem of heart failure, confirmed by echocardiogram

Referral guidelines

• Patients who have had admissions to hospital with symptoms of heart failure within the last 12 months.
• Patients who have complex psychosocial or spiritual needs.
• Patients who have been identified by a clinician involved in their care as having a clear need to benefit from attending the programme.

Referral process

• Referrals can be made by any health professional who is involved in the care of the heart failure patient. This may be in primary or secondary care.
• Referrals should be completed on the appropriate referral forms and faxed to the contact number stated on the top of the form (copy of the NYHA Classification can be found in appendix 1).
• Referrals will be responded to within 2 working days and assessed against the suitability criteria.
• The patient will then be assessed in their own home environment. This assessment will be carried out either by the hospice nurses involved in the programme or the Heart Failure Nurse.
• If suitable the patient will receive a letter to confirm a place on the programme. It will also state the commencement date.
• A letter will also be sent to the patient’s GP confirming a place on the programme and when it is due to start.
• The GP will be asked to confirm whether the patient requires oxygen. If this is the case then they will be asked to send a copy of the prescription to the hospice. This will be kept in the patient’s hospice notes.

The Programme

 4.1 Contents of the programme ·         Throughout the 16-week programme the patient will be exposed to information regarding aspects of their heart condition. This will include the anatomy and function of the heart, the role of the kidneys within the disease process; the rational for their respective treatment plan and the importance of self-care management strategies in controlling the disease process itself. This will be interlinked with presentations from members of the multidisciplinary team involved in the heart failure care pathway. The discussions include the pharmacology management of heart failure, the necessary lifestyle adjustments, suitable exercise regimes and psychological coping mechanisms necessary to deal with the complex issues which surround living with heart failure on a day to day basis. Alongside this complementary therapies will be offered which can help to assist in controlling the associated symptoms linked with heart failure.

 If it is felt that the patient has gain maximum benefit from attending then they will be encouraged to join the heart failure support group. However if the team feels that the patient requires further support and education and would benefit from reattending the programme then the patient will be invited back when the new programme commences.

 If the heart failure nurse deems the patient’s condition stable then they will become inactive patients on the heart failure caseload. This will mean that they can access the service by contacting the heart failure nurse if they have any problems.

 A letter will be sent to the appropriate GP confirming whether the patient has successfully completed the programme or whether they have been invited back. The Heart Failure Nurse will also specify whether the patient remains active or inactive on the heart failure caseload.