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

Project Summary:

This joint working project will involve the extension the current hospital-based specialist HF service through the deployment of two “in-reach” Heart Failure Specialist Nurses (“HFSNs”), one at each of the hospitals involved (Royal Free and Barnet), with the purpose of:

  1. identifying and triaging HF patients (both at acute medical receiving units and when already admitted via General Medicine/other 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.
  2. the implementation of MDT care for HF patients. This care will be delivered by HF specialist consultants, doctors, nurse specialists, and, where appropriate, pharmacists, physician associates, physiotherapists, palliative care specialists, psychologists, occupational therapists, patient navigators 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 at point (1) above.

Planned Milestones:

Joint Working Project (JWP) to run for 42 months from the scheduled commencement date of execution of this document:

  • develop in-patient strategies/protocols and implementation procedures governing the clinical operations of the HF Service (Milestone 1);
  • advertise posts and secure employment of 2x HFSs or equivalent healthcare professionals on-boarding and familiarisation; complete collection of baseline comparator data for the project outcomes  : (Milestone 2);
  • completion of the first new clinical MDT (Milestone 3)
  • carry out clinical operations according to the developed protocols, monitor and collect data at end of first 6, 12, & 18 months (Milestones 4, 5 & 6)
  • analyse data, prepare and submit the business case to the relevant body for recurrent funding of this service by RFUHT (Milestone 7);
  • Engage Visions4Health to create a 3,000 word first draft report.  Paid directly by Novartis to Visions4Health, an independent third party medical writing provider (Milestone 8)
  • submit final JWP report to Novartis (Milestone 9).

At each Milestone, the joint working partner shall submit relevant documentation providing evidence of the achievement of the same Milestone; provision of said documentation shall count towards the achievement of the relevant Milestone.

Expected Benefits:

The following measures will be evaluated by the Trust:

  1. development of an in-patients strategy/protocol and implementation procedures of the same to govern the clinical operations of the Integrated Heart Failure Service (the “HF Service”);
  2. reduction of unplanned readmission rates within 28 days (against a baseline taken from Hospital Episode Statistics data for the previous year leading into the joint working project;
  3. increase in uptake of and access to NICE approved HF technologies (against a baseline provided by the Trust);
  4. positive increase against the following baseline percentage (%) measures as stated in the most up to date National Institute for Cardiovascular Outcomes Research HF audit (whether published or not) for Royal Free and Barnet hospitals:
  • input from Consultant Cardiologist;
  • input from specialist;
  • ACEI on discharge;
  • ACEI/ARB on discharge;
  • Beta blocker on discharge;
  • MRA on discharge;
  1. patient satisfaction linked to the HF Service (PREMS).

Start Date & Duration: September 2019, for 42 Months