Project Name: Collaborative Working Service improvement for the detection and treatment of Heart Failure (“HF”) in secondary care (“Integrated Nurse Programme”)

Project Summary:

The Project main objective is to improve the quality of care delivered to HF patients under the care of the Hospital in line with NICE guidance. The Project will involve: 

The introduction of the 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). This is to ensure they can be appropriately referred to the relevant Cardiology service, receive specialist HF input and aid in coordinating the discharge of patients to ensure continuous appropriate care for HF patients after their discharge from hospital. 

The implementation of a weekly Multi-Disciplinary Team (“MDT”) care for HF patients delivered by HF HCP specialists. 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 as described at point (1) above. 

Planned Milestones:

  • Kick Off Meeting 
  • Collection of baseline data, in line with the  Project Outcome Measures & Data Collection table 
  • Confirmation of recruitment of Band 8a Nurse Specialist & Band 4 admin 
  • Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity   
  • Collection & submission of 3 months clinical activity data & Project Review meeting to discuss project progress. 
  • Collection & submission of 6 months clinical activity data &Project Review meeting to discuss project progress. 
  • Collection & submission of 9 months clinical activity data & Project Review meeting to discuss project progress. 
  • Collection & submission of 12 months clinical activity data & Project Review meeting to discuss project progress. 
  • Development of business case 
  • Submission of business case by the CW Partner HF team to relevant body within the NHS Board 
  • Submit final CWP report to Novartis within 3 months completion of the clinical work 

Expected Benefits:

Anticipated benefits to patients: 

  • Improved access to optimal diagnosis and treatment. 
  • More equitable and consistent care and access to care; and 
  • Enhanced experience for HF patients and carers who live with HF due to access to HF specialist service.

Anticipated benefits to the CW Partner:

  • Increased overall quality of care and improve equity of access to specialist care for patients with HF. 
  • Improved patient flow and reduced total number of inpatient bed days due to HF; 
  • Increased proportion of patients with HF being managed in accordance with NICE guideline standards; and 
  • Insight into benefits of an inpatient HF service which may inform ongoing redesign and workforce planning.

Anticiapted benefits to Novartis:

  • Further opportunities for the appropriate use of cardiology licensed medicines in line with NICE guidelines, including Novartis’s medicine. 
  • Improved reputation. 
  • Improved professional and transparent relationship and trust between Novartis and the NHS.

Start Date & Duration: December 2023 for 18 months

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