Project Name: Service improvement for the detection and treatment of Heart Failure (“HF”) in primary care

Joint Working Project Summary:

  • The principal aim of this joint working project is to improve the detection and treatment of HF in primary care via an Integrated Care Clinics (“ICCs”) solution consisting of a quality improvement program to ensure better awareness, identification and management of and outcomes for, patients with HF in primary care
  • The project will promote a proactive integrated approach to HF care overall, together with a service evaluation, to deliver the benefits to patients of improved management by promoting active HF case finding, and titrating medication to optimal levels

Expected Patient Outcomes for this Project:

This program will include the following:

  1. increased accuracy and validity of the defined HF population in GP practices via primary care data cleansing, searches and actively identifying new HF patients and existing HF patients receiving sub-optimal care
  2. undertaking a virtual triage to identify patients that require optimised care within the patients’ cohort identified according to the databases searches mentioned above
  3. in-practice HF Medicines Optimisation Clinics for identified patient cohort that require general HF intervention
  4. increased integration and access to specialist HF input and intervention via community based HF specialist clinics
  5. increased awareness, confidence and competence particularly across ‘non-specialist’ primary care healthcare professionals in the management of HF patients
  6. an algorithm embedded within EMIS-systems (with triggers) to ensure sustainability of the HF patients’ management system by providing prompts/reminders for HF patient diagnosis and management
  7. in addition, implementation of Multi-Disciplinary Team (“MDT”) care for HF patients delivered by HF specialist, HF nurse specialist, GP, Pharmacist, 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 patient identified as requiring specialist intervention at the new HF Patient Optimisation Clinics

Start Date & Duration: 31st December 2018, 39 Months

UK2201057725 | January 2022