NHS England has set out an approach to managing heart failure at home that has given healthcare providers the opportunity to access funding and improve heart failure care through personalised care, remote monitoring and integrated services. The approach is called Managing Heart Failure @home and it advocates excellent, integrated heart failure care to help people to live well with heart failure. NHS England has developed and brought together a range of resources to support heart failure teams delivering the approach later this year, including tools to support people living with heart failure.

Increasing access to personalised care is a priority in the NHS Long Term Plan with a commitment to deliver personalised care to 2.5 million people by 2023/24 and to double that within a decade. At its core, Managing Heart Failure @home is a personalised care intervention. It encourages movement away from service-based models, towards a person-centred approach, to support people living with heart failure to have a facilitated conversation with their healthcare team to choose what works for them. Shared decision making and enabling choice can help to empower patients to voice their needs and have the knowledge, skills and confidence to manage their own health.

Managing Heart Failure @home therefore allows patients to thrive through supported self-management. The approach encourages teams to prioritise education, helping people and their carers to become knowledgeable about their symptoms, health data and medications. For example, in Stoke, two digital tools – Recap Health and Florence (Flo) – are used to support and educate heart failure patients following treatment for decompensated heart failure, along with the Pumping Marvellous Traffic Lights symptom checker tool. This has resulted in patients utilising this approach being 42% less likely to be readmitted to hospital within six months, compared to similarly aged patients and 92% of patients saying they were more confident in managing their condition. Well informed patients recognise when they need help, in keeping with national initiatives such as patient initiated follow up, a priority laid out in NHS England’s Operational Planning Guidance.

We must embrace remote support and monitoring, championing innovation whether that be through phone communication, web-based or app interfaces or by collecting patient observations remotely. Using these methods, we give control to patients allowing them to take more responsibility for their health and, through symptom recognition, to proactively seek advice from healthcare services in a timely manner. Heart failure teams can then choose appropriately to offer face to face, remote consultations or a hybrid approach.

Finally, all clinicians want to provide personalised care to their patients but often struggle to do so within the confines of the current system. Services need to adapt to ensure patients are looked after by the right health care professional at the right time, be that their GP practice team, community heart failure team, in virtual wards or at their local hospital. Services must communicate effectively, providing integrated care between primary, secondary and community care settings, ensuring excellent patient experience. People should move seamlessly through different parts of the health and care system; maximising quality of care and ensuring personalised care and support planning is effective. The Managing Heart Failure @home approach is consistent with the NHS Long Term Plan recommendation that heart failure patients should be better supported by multidisciplinary teams. People are supported from diagnosis through their entire heart failure journey, linking into palliative care services if and when they are needed ensuring:

• a smooth transition with follow ups in place a maximum of two weeks after discharge from an acute setting
• supporting patients in their journey back home and into primary care and providing opportunities to optimise their treatment
• and prevent deterioration of their condition.

Early adopter sites have now been selected to implement Managing Heart Failure @home in their local areas; allowing services to consciously redesign systems putting the patient at the heart of everything we do.

This is an exciting time for heart failure care. If you want to find out more about how Managing Heart Failure @home could support your working practices and help you deliver personalised care for your patients, visit our Managing Heart Failure @home FutureNHS page (log in required) or get in contact with the @home team by emailing england.home@nhs.net.