How managing heart failure @home helps patients to live well with heart failure

As the Lead Advanced Clinical Practitioner for Cardiac Support Services in North Devon and the Nurse Forum Chair for the British Society for Heart Failure, I know that advancements in heart failure care are essential to meet the demands of the increasing population of heart failure patients.

As management options are evolving, we can now do more to keep patients well if we can improve timely access to specialists, providing individualised, targeted care. Transforming the way we deliver heart failure care is crucial to meet the growing need effectively.

Staff working within NHS heart failure services are facing significant challenges. COVID-19 has created the need to reimagine services, and over the last two years staff have embraced new ways of working, acquiring new skills and showing huge resilience and enthusiasm despite the most difficult of circumstances.

Managing Heart Failure @home, part of NHS @home, can help nursing teams tackle their busy schedules, enabling us to retain valued staff and increase the heart failure nursing workforce.

Now is a great time to re-evaluate our working practices to ensure we are delivering contemporary and effective services. Whilst Managing Heart Failure @home will be a key part of that, increasing the heart failure nursing workforce is also going to be essential.

Managing Heart Failure @home is an approach to deliver best practice care in hybrid ways to patients in the community.

Three elements define the approach:

  • Taking a personalised care approach to ensure services are responsive to a patient’s holistic needs, allowing them to confidently self-manage their condition.
  • Remote support and monitoring, allowing teams to work in innovative ways and enhancing services with the latest digital technologies (where clinically appropriate).
  • Integrated care, to ensure all parts of the healthcare system work effectively together to provide patients with coordinated care from the right team at the right time.

Managing Heart Failure @home champions best practice care, supports teams to use their workforce and resources effectively and draws on learning from heart failure services which are already working in innovative ways:

  • In Birmingham all heart failure specialist nurses were trained in cardiac rehabilitation through the British Association for Cardiovascular Prevention and Rehabilitation allowing them to apply the principles of rehabilitation throughout their working practices and provide more personalised care.
  • At the Royal Stoke University Hospital, two digital tools, Recap Health and Florence, were used to monitor and educate heart failure patients following treatment for decompensated heart failure. This remote support and monitoring reduced hospital readmission rates and had a positive impact on heart failure care, as patients felt they improved their ability to manage their own health.
  •  A further example is the Southampton Heart Failure Model which showcases integrated care. They decided to adopt a working pattern which saw their specialist nurses rotate in and out of hospitals, so that nursing teams benefited from understanding the entire patient journey, as well as learning management skills and updating their clinical skillset.

Many of these new ways of working have already positively impacted on the working lives of NHS staff and have helped to build the Managing Heart Failure @home approach.

Managing Heart Failure @home also provides further opportunities to encourage staff to flourish through multi-disciplinary team working.

Reconsideration of services and improving cross-boundary working can allow more flexible provision of care, meaning the right patients get to see the right teams at the right time. Reducing admissions through robust care practices could also allow redirection of resources to where it is needed most, for example, to more robustly serve our seldom heard, seldom seen communities. By welcoming other health professionals into heart failure teams, we can enhance patient care by increasing skill mix.

NHS England are now selecting Early Adopter sites to trial a Managing Heart Failure @home approach. With the opportunity to employ project managers and/or provide backfill for clinical leadership support as well as supporting postgraduate learning and development, there is a real opportunity for teams to become the architects of more efficient, more effective, more personalised care for their heart failure patients.

For more information on Managing Heart Failure @home visit the FutureNHS page (login required), or contact 

Poppy Brooks

Poppy is the Lead Nurse for Cardiac Support Services at Royal Devon University Healthcare NHS Foundation Trust (Northern services). Poppy practices as a Heart Failure Specialist Nurse in an integrated heart failure service, covering both in-patient and community care.

Poppy has worked in cardiology for 20 years, initially on the coronary care unit at Southampton General Hospital, before moving to North Devon to specialise in heart failure in 2015. Poppy has completed specialist post registration education at Masters level and is a non-medical prescriber.

Poppy is Chair of the British Society for Heart Failure (BSH) Nurse Forum and also volunteers on the BSH policy and media committee. Poppy has written articles and editorials both independently and on behalf of the BSH. She previously represented the BSH on the Editorial Board of the British Journal of Cardiac Nursing.

Poppy is passionate about highlighting the essential role of the heart failure nurse specialist (HFSN), particularly the urgent need to grow the specialist workforce in heart failure and meet the needs of this complex group of patients.