Long Term Conditions Heart Failure. Integrated Heart Failure Team. 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
Integrated Heart Failure Team
1 Heart Failure Specialist Nurse (GW)
3 Heart Failure Specialist Nurses
Integrated Service (Jan 2013)
4.5 Heart Failure Specialist Nurses
Croydon, CR9 2RS
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.
Trigger assessment to help clinician and patient determine stage of disease. Establish base line.
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
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
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.
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