Primary care network offers extra support for high-risk group with heart failure and social isolation

Case study summary

A primary care network has helped 37 people in Bedfordshire with heart failure get extra medication reviews, assessment of their social support and assess any issues with isolation or housing.

The Titan Primary Care Network team identified the group, which had suspected or confirmed heart failure and were at risk of deteriorating due to social vulnerability, using a population health management approach.


Bedfordshire, Luton and Milton Keynes Integrated Care System (ICS): Titan Primary Care Network (PCN).

What was the aim?

This project aimed to improve the health and wellbeing of people with suspected or confirmed heart failure by:

  • addressing the wider determinants affecting their health
  • improving their access to existing health services
  • optimising their medication
  • improving patients’ activation and health literacy.

The PCN wanted to offer them more personalised help to improve their health and wellbeing and reduce health inequalities.

What was the solution

A team including GPs, data analysts, social prescribers, clinical pharmacists, care co-ordinators and a community heart failure nurse worked together on the Population Health Management (PHM) Development programme project, which has now been offered in every area in the country.

PHM helps integrated care systems, like this one in Bedfordshire, Luton and Milton Keynes, understand and predict future health and care needs, reduce health inequalities and make better use of resources.

Read a seven minute version of this case study on the PHM Academy and watch social prescriber Victoria Harding talk about the programme. You will need to register for a FutureNHS account to view the case study and video.

The PCN analysts linked general practice and acute datasets together to understand the impact of social isolation on people with heart failure with the aim to identify a group in the highest risk categories who would benefit the most from a more intensive help.

The GP team agreed and wrote to the cohort inviting them to take part followed by phone calls, home visits with the social prescriber and work with the heart failure nurse and pharmacist to review medicines.

They assessed social support arrangements, social circumstances including isolation and accommodation as needed and encouraged the patients to self-manage their condition where appropriate. Where patients needed ongoing support, they were placed in the wider multi-disciplinary team group.

What were the challenges

As a small PCN with a limited workforce, the scale and pace of this work was impacted by other priorities such as COVID vaccinations. The team worked well together and adapted to these challenges.

There were challenges with coding from primary and secondary care. They identified 116 patients living with heart failure with high deprivation index scores, and after assessing their care records found 37 people who could benefit from being reviewed by one of their team, either a social prescriber, care coordinator, GP, pharmacist or heart failure nurse.

Among other reasons, the number of patients identified was lower than the original, as during COVID patients haven’t always been able to take up a virtual offer and teams did not have the capacity to see everyone – the PCN has therefore been taking forward the highest risk patients first.

What were the results

So far:

  • 116 people have been identified
  • 37 of these were deemed suitable to benefit
  • 41 patients were invited to take part – which included four identified by the heart failure nurse.

Jane’s story

As well as heart failure, Jane had diabetes, schizophrenia, learning difficulties and a thyroid problem. She frequently called GP out of hours or 999 whenever she needed health advice.

After the social prescriber visited her in her home, she understood much more about Jane.

Despite having various long-term conditions, Jane had a very limited understanding of her health. She was overweight, and often became breathless and dizzy. She had generally poor eyesight, related to her diabetes, but hadn’t had a recent eye test.

She pretty much spent every day in the front room, but she slept on the couch, had no TV, and the other furniture wasn’t in the best condition. Her ceiling was really poorly decorated – it looked like the whole thing was about to come down.

Titan Primary Care Network’s Wellbeing team prioritised the much-needed repairs to her flat and reviewed her benefits. They introduced some chair-based exercises and made her personal shopper aware of her diabetes to help improve her diet. The pharmacy team optimised her medication, and she has an appointment with the community heart failure team to review her condition.

By building up her knowledge base of what to do in different situations, she has not called 999 or the GP out of hours since the team made contact. Her self-assessed outcome scores have improved, and she says she feels fantastic now her home has been redecorated, she’s eating better, able to get out more and feeling less isolated. Thanks to the PHM project, they were able to get a clearer picture of Jane’s situation and make sure she got the extra support she needed.

Read Jane’s full story.

What were the learning points?

Through this project, the PCN has recognised the importance of the care coordinator role and having a dedicated team focussed on the intervention. They have therefore decided to redeploy a member of staff into the care coordinator role while waiting to recruit permanently.

They understand that access to linked data is vital, but equally important is the support that allows staff at each level of the system to understand, interpret and operationalise the insights that can be gained.

PHM analytics will be a key part of the intelligence available to the ICS and care alliances as they develop care quality, efficiency, and equality improvement schemes.

Close links between care providers and local community groups and assets has proved invaluable in making the insights gained from PHM data actionable.

Using learning from the pilot cohort, they plan to use data to proactively look for patients who are socially vulnerable and have recurrent admissions for heart failure and are not engaging with primary care.

On average, the cohort costs around £7,500 per person per year in non-elective admissions. The PCN plan to review unplanned admissions every quarter to measure the impact of their intervention. Follow-up will be via the care coordinator and the social prescriber.

There is scope to look at patients with related cardiovascular presentations like atrial fibrillation and hypertension. They aim to adopt a PHM based approach in fulfilling the PCN DES.

The intervention is easily scalable, and the PCN plan to share their learnings from their cohort.