Community Heart Failure Team

About the service

The team works with patients in the community to help them support and manage their conditions. We help patients with treatment reviews, symptom control and provide support and education for patients and family members or carers.

All patients are supported through an individualised care plan, patient-held health record and a point of contact for the service via the 'single point of access' (SPA).

What we do

As a team, the Heart Failure Nurses provide care by:

• Managing complex drug regimes and encouraging compliance
• Titration of Heart Failure medication in line with NICE Guidelines
• Monitoring patient response, bloods and organ function following drug changes
• Liaising with acute hospital Heart Failure specialists - both nurses and consultants - to create a 'pull' model for early discharge
• Educating patients and carers to know how to recognise and manage exacerbations - thereby avoiding unnecessary admission and taking control of their condition
• Encouraging lifestyle improvements including, in association with relevant professionals, advice about exercise and diet
• Utilising tele-monitoring and monitoring vulnerable patients daily via the remote system
• Tailoring care to individual patient needs and provide individualised care plans
• Ensuring all Heart Failure patients benefit from flu and pneumococcal immunisation
• Delivering improved patient and carer experience at the 'end of life' - including, where appropriate, de-activation of intra-cardiac devices in conjunction with appropriate palliative care teams
• Build on and encourage best practice in primary care by providing education to other healthcare professionals and providing advice when sought
• Improve the prognosis and quality of life for Heart Failure patients by improving symptoms and slowing their deterioration.

Accessing the service

Patients are referred into the service by their GP or healthcare professional.  We are unable to accept self-referrals.