A dedicated contact for follow up care
- 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 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: