Managing heart failure @home

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

Living with heart failure is becoming increasingly common. In the UK, 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. It is now estimated that diagnosed cases are predicted to nearly double by 2040.

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 safely continuing to be supported. Enabling supported self-management to understand signs and symptoms and seek early intervention when recognising deterioration is significant to keeping people living well at home, while avoiding unnecessary hospital admissions.

Commissioned by Health Innovation Network South West, MTech Access has evaluated the effectiveness of the MHF @home approach. The evaluation report was published in December 2024. Its key findings include:

  • patients experienced an improvement in health-related quality of life, heart failure related symptoms and ability to manage their heart failure
  • patients accessing MHF @home experienced a reduction in their use of primary care services.

Whilst many test sites saw a reduction in patients’ use of secondary care services, additional analysis is being undertaken to better understand the variation between sites, this includes exploring the impact of MHF @home on both inpatient and outpatient contacts. If you have any questions about the programme and its ongoing evaluation, please email england.ctp@nhs.net

Managing heart failure @home sites

NHS England is supporting MHF @home sites across England.

Phase 1 – From March to September 2021, 5 demonstrator sites were supported 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 (NHS @home FutureNHS platform, requires users to register and log-in).

Phase 2 – The evidence from the 5 demonstrator sites was consolidated along with interviews with key stakeholders and desk research to support the case for change for a new model of care, harnessing 3 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 new ways of working to integrate services 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.

Phase 3 – NHS England selected 10 early adopter and accelerator sites to implement the MHF @home approach into their heart failure service from November 2022 to May 2023. Each organisation received funding for 6 months to support project set up and upskilling staff.

Phase 4 – In 2024, 7 of the 10 sites received additional funding to continue implementation of MHF @home with a focus on scaling their approach and to contribute to further evaluation. In addition, 18 new sites received funding to implement MHF @home.

Continuing sites

  • East and North Hertfordshire Health and Care Partnership
  • University Hospitals of North Midlands
  • Frimley Health NHS Foundation Trust
  • Haringey GP Federation
  • North Tees and Hartlepool NHS Trust
  • University Hospital Coventry and Warwickshire NHS Trust
  • University Hospital Southampton NHS Foundation Trust

New sites

  • Barts NHS Trust
  • Berkshire Healthcare Foundation Trust
  • Chesterfield Royal Hospital
  • Dartford, Gravesham and Swanley Health and Care Partnership
  • Dorset County Hospital
  • Kings College Hospital NHS Foundation Trust
  • Lincolnshire Community Health Services NHS Trust
  • North Sedgemoor PCN Somerset
  • One Health Lewisham
  • Portsmouth University Hospital
  • Shrewsbury and Telford Hospitals NHS Trust
  • Somerset Foundation Trust
  • South Tees NHS Acute Hospital Trust
  • Tameside and Glossop Integrated Care NHS Foundation Trust
  • University Dorset Hospitals Trust
  • Wirral Community NHS Trust
  • Oxford University Hospitals NHS Foundation Trust and Buckinghamshire Healthcare NHS Trust
  • Provide health Mid and South Essex

What support is available for NHS system and healthcare professionals?

What support is available for people, carers and families?