Project Name: Creation of an In-Reach and Out-Reach Heart Failure Service for Cwm Taf North

Joint Working Project Summary:

The Joint Working Project will involve the introduction of a hospital-based in-patient service and fortnightly community-based diagnostic clinics. The service will offer ongoing self-management advice and psychological support for patients and their carers. It will also be a point of call for GPs and other health care professionals within the hospital and local area, requiring advice for Heart Failure patients, streamlining and improving communication between primary and secondary care.

Expected Patient Outcomes for this Project:

The following measures will be evaluated by the Trust:

  • timely specialist assessment and management of patients. In particular those:
    • with a possible new diagnosis of HF;
    • with a new ascertained diagnosis of HF;
    • with decompensating symptoms, from
    • within the hospital (emergency department) or outside of the hospital setting;
    • recently discharged from hospital with
    • decompensated HF;
  • early future management plans, i.e.: palliative care, revascularisation, device therapy, etc.
  • oversight of individual management plans by a HF specialist;
  • care closer to home where possible, including clinics in Kier Hardie Health Park, a local primary care facility;
  • improved Primary Care referrals for HF diagnosis and management;
  • self-management advice;
  • psychological support for patients and their carers; and
  • a link into primary care/community teams to
  • facilitate transfer of care post-discharge.

Start Date and Duration: 30th July 2019, 34 Months

UK | July 2021 | 253303