Managing heart failure @home

Managing heart failure @home is an approach that aims to support people to better manage their heart failure condition and keep well at home.

Living with heart failure is becoming increasingly common. In the United Kingdom, heart failure affects approximately 920,000 people with 200,000 new cases annually, and these numbers are increasing due to an ageing population and improved survival rates after a heart attack.

To help keep vulnerable people safe and routine services going during the early stages of the COVID-19 pandemic, the NHS accelerated the shift to remote forms of care. Remote monitoring, when clinically appropriate and right for the individual, has changed how people with heart failure receive care, allowing people to stay at home while continuing to be supported safely. This, coupled with increasing supported self-management so people can better understand signs and symptoms of deterioration and seek earlier intervention, can make a significant contribution to keeping people living well at home, avoiding unnecessary hospital admissions.

What is the managing heart failure @home approach?

Five demonstrator sites were supported from March to September 2021 to develop and test approaches using remote monitoring and education, to better support people with heart failure in the community.

This work demonstrated opportunities to improve health outcomes and patient experience including a reduction in unnecessary face-to-face appointments, improvements in patients’ knowledge, skills and confidence in remote monitoring and self-management, improving cost per patient and reducing staff time per patient. Read the learning from the demonstrator sites summary report on the NHS @home FutureNHS platform (requires users to register and log-in).

The evidence from the five demonstrator sites has been consolidated along with interviews with key stakeholders and desk research to support the case for change for a new model of care, harnessing three core elements: personalised care, remote monitoring and integrated care.

  1. Personalised care means people have choice and control over the way their care is planned and delivered, based on what matters to them, and their individual strengths, needs and preferences. Personalised care also champions shared decision making and supported self-management to help empower people with the knowledge, skills and confidence to manage their own health in their homes.
  2. Remote support and monitoring supports people to recognise the signs and symptoms to escalate, if their condition deteriorates, by using digital technologies and accessible information to help avoid unnecessary admissions to hospital or face-to-face appointments with healthcare services.
  3. Integrated care includes using multi-disciplinary teams and improve coordination between primary, community and secondary care. Integrated care allows for systems and processes to identify patients with heart failure earlier, stratifying them so that those most at risk of deterioration or hospital admission can be supported to manage their heart failure at home.

What are the next steps for the managing heart failure @home approach?

NHS England has selected ten early adopter and accelerator sites to implement the managing heart failure @home approach into their heart failure service from November 2022. Each organisation has received funding for six months to support project set up and upskilling staff. The outcomes and learning will be shared nationally to support wider implementation.

The ten sites are:

  1. Wargrave, Belmont and Cantilupe Primary Care Network
  2. East and North Hertfordshire Health and Care Partnership
  3. University Hospitals of North Midlands
  4. Wiltshire Health and Care
  5. Frimley Health NHS Foundation Trust
  6. Haringey GP Federation
  7. Blackpool Teaching Hospitals NHS Foundation Trust
  8. North Tees and Hartlepool NHS Trust
  9. University Hospital Coventry and Warwickshire NHS Trust
  10. University Hospital Southampton NHS Foundation Trust

What support is available for NHS system and healthcare professionals?

  • Patient information booklet to support healthcare professionals with conversations with patients about managing heart failure @home.
  • Approach and pathway on NHS @home FutureNHS platform (requires users to register and log-in).
  • Case studies on NHS @home FutureNHS platform (requires users to register and log-in).
  • Professor Nick Linker, National Clinical Director for Heart Diseases, talks more about the managing heart failure @home approach in this NHS England blog post.
  • Poppy Brooks, Lead Advanced Clinical Practitioner for Cardiac Support Services in North Devon and the Nurse Forum Chair for the British Society for Heart Failure talks more about how managing heart failure @home helps patients live well with heart failure in this NHS England blog post.
  • Nick Hartshorne-Evans, Chief Executive of the Pumping Marvellous Foundation, talks more about putting patients at the heart of heart failure services in this NHS England blog post.
  • Dr Sam Finnikin, GP, researcher at the University of Birmingham and National Clinical Specialist Advisor in Personalised Care at NHS England, and Dr Jim Moore, GP, Clinical Lead for the NHS England Cardiac Pathways Implementation Programme and President of the Primary Care Cardiovascular Society, talk more about how Managing Heart Failure @home supports existing healthcare priorities in this NHS England blog post.
  • Cardiac Pathways Improvement Programme FutureNHS platform (requires users to register and log-in).
  • A community of practice is in development, please join the MHF @home FutureNHS workspace for updates.
  • The Personalised Care Institute equips health and care professionals to deliver universal personalised care that takes into account an individual’s strengths, needs and expectations, in order to deliver the right care for them.

What support is available for people, carers and families?