Multidisciplinary, person-centred care

“Heart failure care does not stop in the hospital – it has to span across all settings of care and focus on improving the quality of life of each person living with heart failure.”

Pascal Garel, Secretary-General of the European Hospital and Healthcare Federation (HOPE)

“The frustrating thing with heart failure is that we know what works to help improve patients’ lives - we are just not applying it as consistently as we should.”

Dr Mark Dancy, cardiologist and clinical lead of NHS Improvement Programme on Heart Failure

Overview

Clinical guidelines for heart failure exist, however many people with heart failure still do not get the right treatment,1 even in hospital.

Evidence has shown that patients who receive input from a cardiologist2 are given evidence-based treatment to help stabilise their condition and are discharged from hospital with a clear discharge and follow up plan3.These patients have a lower risk of being re-admitted to hospital or of dying within one year.4

Heart failure is a long-term condition. A key care goal must therefore be to help patients engage in their care and maintain as good a quality of life as possible over the course of their condition. To do this, patients need a personalised care plan tailored to their individual needs.

Economic case

  • Outcomes for people with heart failure are worse than breast, prostate and bowel cancer.4
  • Modern, evidence-based medications or devices are available in some countries that improve survival for many types of HF.7 However, they are not always used appropriately.7
  • Multidisciplinary, specialist-led care for patients hospitalised with heart failure is cost-effective,8 reduces length of stay9 and leads to lower rates of hospital re-admissions10 and death.11
  • One in 4 patients discharged from hospital is re-admitted within one month.12
  • Over half of these admissions could be avoided through careful discharge planning, appropriate patient education and personalised follow up in the community.13

The Patient's view

“I was in hospital for a week before I was even correctly diagnosed. Finally, in the cardiac unit, I had a sense of relief that I was in a place where they knew what they were doing. The day after the cardiologist had been, all the drugs were administered and I was put on IV diuretics and as the weight came off I started to feel as though it was achievable. And there was an element of achievability here that if I got the right therapies, the right drugs and treatment that maybe heart failure wasn’t about failing.”

Nick, a man living with heart failure

“Health professionals should look at the person holistically, ensuring our mental health is taken care of and referral to other services if needed. The journey is different for everyone, therefore services should be flexible.”

Liz, a woman living with heart failure

Priorities for action:

Click for more details

  • Ponikowski P, Anker S, AlHabib K, et al. Heart failure: preventing disease and death worldwide. : European Society of Cardiology., 2014.

  • British Society for Heart Failure. National Heart Failure Audit April 2012-March 2013. University College London.: National Institute for Cardiovascular Outcomes Research., 2013.

  • Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence? Critical care nurse 2008;28(2):66-82.

  • Cowie MR, Anker SD, Cleland JG, et al. Improving care for patients with acute heart failure Before, during and after hospitalization. Heart Failure Association of the ESC 2014.

  • Cowie MR, Anker SD, Cleland JG, et al. Improving care for patients with acute heart failure Before, during and after hospitalization. Heart Failure Association of the ESC 2014.

    Sutherland K. Bridging the quality gap: Heart failure.: The Health Foundation 2010.

  • Stewart S, MacIntyre K, Hole D, et al. More ‘malignant’ than cancer? Five-year survival following a first admission for heart failure. European Journal of Heart Failure 2001:315-22.

  • Komajda M, Follath F, Swedberg K, et al. The EuroHeart Failure Survey programme—a survey on the quality of care among patients with heart failure in Europe. European Heart Journal 2003;24(5):464-74.

  • Ledwidge M, Barry M, Cahill J, et al. Is multidisciplinary care of heart failure cost-beneficial when combined with optimal medical care? Eur J Heart Fail 2003;5(3):381-9.

  • Anguita Sánchez M. Clinical Characteristics, Treatment and Short-Term Morbidity and Mortality of Patients With Heart Failure Followed in Heart Failure Clinics. Results of the BADAPIC Registry. Rev Clin Esp 2004;57(12):1159-69.

    Anguita Sánchez M, Ojeda S, Atienza F, et al. Análisis de coste-beneficio de los programas de prevención de reingresos en pacientes hospitalizados por insuficiencia cardíaca. Impacto económico de las nuevas formas de asistencia a la insuficiencia cardíaca. Revista Española de Cardiología 2005;58(Supl 2):32-6.

    Roccaforte R, Demers C, Baldassarre F, et al. Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis. Eur J Heart Fail 2005;7(7):1133-44.

  • Ledwidge M, Barry M, Cahill J, et al. Is multidisciplinary care of heart failure cost-beneficial when combined with optimal medical care? Eur J Heart Fail 2003;5(3):381-9.

    Roccaforte R, Demers C, Baldassarre F, et al. Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis. Eur J Heart Fail 2005;7(7):1133-44.

    Zuily S, Jourdain P, Decup D, et al. Impact of heart failure management unit on heart failure-related readmission rate and mortality. Archives of Cardiovascular Diseases 2010;103(2):90-96.

    McAlister FA, Stewart S, Ferrua S, et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admissionA systematic review of randomized trials. Journal of the American College of Cardiology 2004;44(4):810-19.

  • Roccaforte R, Demers C, Baldassarre F, et al. Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta-analysis. Eur J Heart Fail 2005;7(7):1133-44.

    Zuily S, Jourdain P, Decup D, et al. Impact of heart failure management unit on heart failure-related readmission rate and mortality. Archives of Cardiovascular Diseases 2010;103(2):90-96.

    McAlister FA, Stewart S, Ferrua S, et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admissionA systematic review of randomized trials. Journal of the American College of Cardiology 2004;44(4):810-19.

  • Cowie MR, Anker SD, Cleland JG, et al. Improving care for patients with acute heart failure Before, during and after hospitalization. Heart Failure Association of the ESC 2014.

    Sutherland K. Bridging the quality gap: Heart failure.: The Health Foundation 2010.

  • Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence? Critical care nurse 2008;28(2):66-82.

    Mocillo C, Valderas J, Aguado O, et al. Evaluation of a Home-Based Intervention in Heart Failure Patients. Results of a Randomized Study. Revista Española de Cardiología 2005;58(6):18-25.

    Roig E, Pérez-Villa F, Cuppoletti A, et al. Specialized Care Program for End-Stage Heart Failure Patients. Initial Experience in a Heart Failure Unit. Revista Española de Cardiología 2006;59(2):109-16.

    Anderson C, Deepak BV, Amoateng-Adjepong Y, et al. Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure. Congestive heart failure (Greenwich, Conn) 2005;11(6):315-21.