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Integrated heart failure care – an evolving service

To mark World Heart Day on 29 September, Lynda Blue, Senior Nurse at Guy’s and St Thomas’ NHS Foundation Trust, blogs about the progress our integrated heart failure service has made two years after launching.

Heart Failure Team suck a lemon challengeI have worked in heart failure for many years and find the work of caring for people with heart failure extremely satisfying. Heart failure is a condition which can cause a greater reduction in quality of life than almost any other medical condition. Symptoms include (but are not limited to) shortness of breath, weakness, coughing, difficulty concentrating, and nausea. However, with appropriate treatment, survival rates and quality of life for patients can dramatically improve.

[Image: The Heart Failure Team taking part in the #suckalemonchallenge as part of the Heart Failure Sucks campaign]

It is estimated that 9,000 people are living with heart failure in Southwark and Lambeth but less than 3,000 are known to healthcare services. To meet this need we launched the King's Health Partners Integrated Heart Failure Service (2016) which was designed to develop innovative integrated pathways for people living with heart failure in our local communities. Initially starting out as a project which would run for two years, supported by Guy's and St Thomas’ Charity, the project was later officially launched as a long-term service.

The service involves staff from our partners Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley NHS Foundation Trusts working together to help people with heart failure live longer and with a better quality of life in their own homes.

Where are we now?

Here are some key highlights since launching the service:

  • Introduction of heart failure locality teams - since January 2016 there are named multidisciplinary teams for the five localities in Southwark and Lambeth. Each locality team comprises a cardiologist a heart failure specialist nurse and a heart failure pharmacist. The clinicians working in the locality teams provide specialist advice and support to GP practices in their allocated area
  • Virtual clinics to support the management of heart failure in primary care - enables GPs to receive specialist advice and education on management of their heart failure patients. Cardiologists, heart failure specialist nurses and heart failure pharmacists review and discuss complex patients and confirm diagnosis and treatment
  • Development of GP education materials - King’s Health Partners specialists worked with GP champions to produce a heart failure referral pathwaybreathlessness assessment algorithm, and prescribing guidelines which have been adopted across south London. These tools are available on DXS (the local GP decision support system) and on the Guy’s and St Thomas’ website under ‘education for GPs’
  • Psychological support for heart failure patients - as part of King’s Health Partners Mind & Body programme, the heart failure teams are working with the 3 Dimensions for Long-Term Conditions (3DLC) project to ensure that mental wellbeing is considered at every stage of a heart failure patient's journey. Depression and anxiety screening tools have been introduced for heart failure patients attending out-patient clinics. Over the last year, 267 patients have been referred for psychological support from the cardiology team. Watch a video of heart failure service user Shawn Collick describing how he benefitted from the help of 3DLC
  • Standardised processes across heart failure nurse teams - a King’s Health Partners heart failure nurse competency framework and a Service Operating Procedure (SOP) have been produced by the heart failure nurse teams to standardise heart failure nursing management across Guy’s and St Thomas’ and King’s College Hospital NHS Foundation Trusts and in the community across Lambeth and Southwark. The competency framework and SOP have been disseminated to other NHS services seeking to adopt the documents and they are also on the British Society of Heart Failure website as examples of best practice
  • Bi-annual nurse study days are being delivered by the heart failure multidisciplinary team to generalist hospital and community nurses to increase their knowledge of heart failure and its management, please contact Silapiya Smith if you are interested in joining the next study day.

It has been an exciting few years and so much progress made.  The focus now is on identifying and planning priorities for the year ahead, reflecting on the findings from our evaluation report (due for publication autumn 2018) and ensuring that momentum is maintained.

We are working collaboratively with colleagues in our partner organisations through the King’s Health Partners Cardiovascular Institute to support the integrated heart failure service to develop and adapt, to deliver efficient and effective care which makes a real difference to the health and wellbeing of our local population.

Integrated Heart Failure Team group picture

[Image: King's Health Partners Integrated Heart Failure Team]