The Living With Heart Failure / COPD (Chronic Obstructive Pulmonary Disease) Programme is a 16-week programme in which you will receive a wide range of information to help support you in living with your condition.

Our aim is to provide support and guidance to you and your carers in order for you to gain a better understanding and control over your heart condition. This will include understanding how the heart functions and the role of the kidneys.

Our objectives

• to provide you, your family and carers with education, advice and support in order for you to become more actively involved with the management and monitoring of your condition.


• to enhance quality of life for heart failure / COPD patients by ensuring you receive an individualized patient management plan. This will enable you to play a more active role in the management of your care.


• to closely 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 your quality of life.


• to promote effective communication between all the members of the multidisciplinary team involved in your 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.

How to get referred

You are eligible to access this programme if you have had a primary clinical problem of heart failure / COPD, confirmed by an echocardiogram and meet one of the following

• you have had an admission to hospital with symptoms of heart failure within the last 12 months.


• you have complex psychosocial or spiritual needs.


• you have been identified by a clinician involved in their care as having a clear need to benefit from attending the programme.

Referrals can be made by any health professional who is involved in your heart failure / COPD care. This may be in primary or secondary care. The information they require to complete the referral is stated below.

What happens at the end of the programme?

The team will meet together prior to the last week of the programme to assess how well you have benefited from attending, and to discuss what will happen once you have finished the programme itself.

If it is felt that you have gained maximum benefit from attending then you will be encouraged to join the heart failure support group. However if the team feels you require further support and education and would benefit from re-attending the programme then you may be invited back when the new programme commences.

If the heart failure / COPD nurse deems that your condition is stable then you will remain on the heart failure caseload and can access the service by contacting the heart failure nurse if you have any problems in the future.

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

Referral process for clinicians

• 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 a specific Heart Failure / COPD 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.