A dedicated contact for follow up care

We need

  • Every patient hospitalised for heart failure to leave the hospital with an individualised discharge plan – to ensure the transition from hospital back to their home is as smooth as possible
  • Discharge plans to include an appointment to see an heart failure specialist within 2 weeks of discharge – to make sure patients’ condition has stabilised and their medication is adapted correctly
  • Every patient to be given a dedicated contact for follow up after they are discharged from hospital – ideally an heart failure specialist nurse who can provide the link between the hospital-based team, the community care team and the patient.


  • Many patients with heart failure feel ‘abandoned’ after they have left the hospital.
  • Patients with heart failure are often discharged before their condition has stabilised or their medication has been appropriately adapted. This can lead to increased risk of re-admission and premature mortality.1
  • Evidence from several countries suggest that follow up care is often poor for patients hospitalised with heart failure. For example:
    • Rehabilitation is a critical part of post-hospital care for patients, however data from the IN-heart failure registry study in Italy found that only 9.1% are discharged to a rehabilitation centre.2
    • A 2009 Swedish study into primary care centres found that nurse-led follow up of heart failure patients was less frequent than in the follow up of patients with diabetes and asthma or congestive obstructive pulmonary disease (COPD).3

Examples of what has been done:

  • Muntwyler J, Abetel G, Gruner C, et al. One-year mortality among unselected outpatients with heart failure. European Heart Journal 2002;23:1861-66.

  • Oliva F, Mortara A, Cacciatore G, et al. Acute heart failure patient profiles, management and in-hospital outcome: results of the Italian Registry on Heart Failure Outcome. Eur J Heart Fail 2012;14(11):1208-17.

  • Martensson J, Dahlstrom U, Johansson G, et al. Nurse-led heart failure follow-up in primary care in Sweden. European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology 2009;8(2):119-24.

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

  • Page K, Marwick T, Lee R, et al. A systematic approach to chronic heart failure care: a consensus statement The Medical Journal of Australia 2014;201(3):146-50.

  • McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European journal of heart failure 2012;14(8):803-69.