Long Term Conditions Heart Failure

1. Long Term ConditionsHeart Failure Integrated Heart Failure Team

2. What's changed? 2012 2013 Hospital 1 Heart Failure Specialist Nurse (GW) Community 3 Heart Failure Specialist Nurses Integrated Service (Jan 2013) Consultant Cardiologist Clinical Fellow 4.5 Heart Failure Specialist Nurses

3. Members of the Team • Grace Williams Team Leader 1.0 wte • Tina Lawton HFNS 1.0 wte • Alison Bentley HFNS 1.0 wte • Jo Rungusumy HFNS 0.6 wte • Vacancy HFNS 1.0 wte • Judy Arnold Bank HFNS • Janak Patel Administrator • Jade Brown Administrator

4. The Team!

5. Heart Failure Clinical Team • Dr Sanjay Kumar, Lead Consultant Cardiologist • Dr Ravi Kamdar, Consultant Cardiologist in Device Therapy, Arrhythmias, Heart Failure Consultant • Dr Suzannah Wilson, SpR in Device Therapy, Arrhythmias, Heart Failure Consultant • Sally Massey Operations Manager, Specialist Medicine, Cardiac & Respiratory, Adult Care Pathways • Dimitrios Karagkounis – CCG/CUH Pharmacist • David Roskams, NHS Croydon CCG

6. Current Service Provision • Service Office Lennard Road Croydon, CR9 2RS • Single point of contact for patients and GP’s • Known pt. self referral • Hospital In-patient review • Discharge Personal Management Plan (PMP) • Post discharge telephone follow-up within 2 weeks in Community • Weekly HF MDT inclusive with Pharmacist

7. Current Service Provision CLINICS • CUH - Ad hoc • Purley War Memorial Hospital – Monday/Friday • Norbury HC-Wednesday • Sanderstead Clinic - Thursday • Woodside HC– Friday • Parkway HC (Twice monthly ) HOME • Domiciliary visits for those who cannot travel.

8. Role of the HF Nurse • Working with local and national HF guidelines • Using a clinical management plan • Ensuring correct Evidence-based medication and up titration, monitoring of symptoms , biochemistry and observations . • Ensuring appropriate investigations for HF have been done. • Referral on to a cardiology consultant if appropriate • Case management of complex patients

9. Role of the HF Nurse • Aim to reduce emergency admissions & and length of stay. • Improved quality of life for patients • Patient empowered through education towards self management of condition • Reviewing those nearing end of life, liaison with palliative care.

10. Current Referral Criteria • Croydon based GP • Confirmed diagnosis of heart failure on Echocardiogram essential • Left ventricular systolic dysfunction • Preserved heart failure/diastolic • HF with valve dysfunction • HF with atrial fibrillation

11. Referrals Sources • GPs • CUH- Cardiology , Medicine , Care of the Elderly etc. • Tertiary centres - SGH, KGH and GSTT • Referrals from MDT ( Rapid Response, Community matrons, Health visitors for older people , District nurses, Stroke team , Palliative care )

12. How to Refer to the IHFNS • Referral form available on CHS website http://www.croydonhealthservices.nhs.uk/Downloads/GP_resources/Referral_information/Cardiology/Croydon%20Heart%20Failure%20Referral%20Form.pdf

13. Heart Failure Service Redesign • GP One Stop HF clinics move into Community • Telehealth Monitoring • Cardiac Rehabilitation • ‘Hot Clinics’ • Community IV diuretic therapy

14. Heart Failure Monitoring & EoLC Slide 1 Heart failure diagnosis and personal treatment plan in place agreed with patient. Patient monitoring & review 6/12 months depending on severity. Telehealth as appropriate. BHF personal record for patient to self manage condition. Escalation plan if condition deteriorates. Next slide TRIGGER TOOL Trigger assessment to help clinician and patient determine stage of disease. Establish base line. 1 1 i i GP advised so additional information can be sent to MDT Patient satisfies two of the criteria on the trigger tool. GP or HFSN to consider whether reflects “end stage” HF Adjust medication and seek specialist treatment e.g. Surgical management biventricular pacing if appropriate MDT - Gold Services Framework/Risk Stratification meetings in primary care will include decisions regarding heart failure patients Information Palliative Care/End of Life pathway with patient & family/carers. Coordinate My Care record established Timeline will be different for all patients depending on deterioration, so regular monitoring by community services clinicians will continue based on needs. Patient choice regarding place of death Steps that are based in primary care Steps that are based in acute Steps that are taken in community services Decision making point Shared decision making with patient Own home Care home Hospice 20/11/2014

15. Advance Planning and End of Life • Gold Standard Framework • Collaborative approach/Joint decision involving the patient, significant other, the GP (Consultant Physician/Cardiologist if an in-patient) and the HF specialist • Involvement of the Palliative care team, St Christopher’s Hospice home support team • Discussion regarding the preferred place of care (PPC) – home, hospice, hospital and when to cease admissions for decompensation of HF or complications related to HF management. Facilitating discharge to die at home • End-of life register- Co-ordinate my care (CMC)

16. TRIGGER TOOL TO RECOGNISE EoLC ( Brent Trigger Tool)THE AIM OF THE TRIGGER TOOL IS TO HELP THE CLINICIAN IDENTIFY THOSE PATIENTS WHO MAY BE ENTERING THE FINAL STAGES OF HEART FAILURE. IF THE PATIENT MEETS TWO OR MORE OF THE FOLLOWING CRITERIA THE CLINICIAN SHOULD CONSIDER DISCUSSING THE PATIENT AT THE MULTI-DISCIPLINARY TEAM MEETING.

17. Future developments • Aim to divide our caseload to align with GP Networks • Work collaboratively by strengthening links with other community services • Attend GP MDT/Risk stratification/GSF Meetings

18. Contact details We are available Monday – Friday, 09.00hrs – 17.00hrs Lennard Road Office Telephone: 020 8274 6416 or 6152 Fax: 020 8274 6174 Croydon University Hospital Telephone: 020 8401 3000 Ext. 4413 Contact via switchboard 020 8401 3000, bleep 772

19. Any Questions?