Project Name: The Development of an Integrated Heart Failure (“HF”) Service

Joint Working Project Summary: 

This joint working project will involve the extension of the current 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) so they can be appropriately referred to the relevant Cardiology service and receive specialist HF input and subsequently coordinating the discharge of patients and liaising with community teams, including primary care, to ensure continuous appropriate care for HF patients after their discharge from hospital.

In addition, the project will implement a Multi-Disciplinary Team (“MDT”) care for HF patients delivered by HF Consultants, HF nurse specialists, Pharmacists, and, where appropriate Physiotherapist, Palliative Care specialist, Psychologist, Occupational Therapist and/or Administrators. 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 described above.

Finally, due to the Covid – 19 pandemic many of the Hf team were redeployed and as they have returned, the cross-site working, a 1 day Novartis workshop is to be run to support the reduction in the variations of care across the service.

Planned Milestones: 

The following measures will be evaluated by the Trust:

  • Advertise posts and secure nurse employment; nurse on-boarding and familiarisation (Milestone 1);
  • Develop in-patient strategies/protocols and implementation procedures governing the clinical operations of the HF service (Milestone 2);
  • Carry out clinical operations according to the developed protocols, monitor and collect data, provide anonymised report containing such data (Milestones 3, 4, and 6 at 6, 12, and 18 months), as applicable, as per the measurement criteria outlined in the “Project Outcomes and Measurement Criteria” section above;
  • Submit attendance list for Novartis provided Advance + Business Skills and NHS Insights Workshop facilitated by JSL Consulting and Associates Limited (Milestone 5).
  • Analyse data, and prepare business case for funding of this service by the NHS (Milestone 7);
  • Submit HF service business case to relevant body within Imperial College Healthcare Trust (Milestone 8);
  • Submit final JWP report to Novartis (Milestone 9).

Expected Benefits: 

For the Patients:

  • improved access to diagnosis and optimised treatment;
  • more equitable and consistent care and access to care;
  • enhanced experience for patients and their carers who live with HF.

For the NHS:

  • increased quality of care and improved equity of access to specialist care for patients with HF;
  • improve patient flow and reduced total number of inpatient bed days and readmissions due to HF;
  • increase proportion of patients identified with HF being managed in accordance with NICE guideline standards;
  • insight into benefits of inpatient HF service which may inform ongoing redesign and workforce planning.

For Novartis:

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

Start Date and Duration: September 2019, 29 months

UK | July 2021 | 306530