Long Term Conditions Heart Failure Integrated Heart Failure Team.

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Long Term Conditions Heart Failure Integrated Heart Failure Team

Transcript of Long Term Conditions Heart Failure Integrated Heart Failure Team.

Page 1: Long Term Conditions Heart Failure Integrated Heart Failure Team.

Long Term ConditionsHeart Failure

Integrated Heart Failure Team

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What's changed?

2012

Community3 Heart Failure

Specialist Nurses

2013 Hospital

1 Heart Failure Specialist Nurse

(GW)

Integrated Service (Jan 2013)Consultant Cardiologist

Clinical Fellow4.5 Heart Failure Specialist

Nurses

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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

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The Team!

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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

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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

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Current Service ProvisionCLINICS•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.

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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

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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.

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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

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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 )

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Heart Failure Service Redesign

• GP One Stop HF clinics move into Community• Telehealth Monitoring• Cardiac Rehabilitation• ‘Hot Clinics’• Community IV diuretic therapy

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Heart Failure Monitoring & EoLCHeart Failure Monitoring & EoLC

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.

Patient satisfies two of the criteria on the trigger tool. GP or HFSN to consider whether reflects “end stage” HF

MDT - Gold Services Framework/Risk Stratification meetings in primary care will include decisions regarding heart failure patients

Care homeOwn home Hospice

GP advised so additional information can be sent to MDT

Next slideTRIGGER TOOL

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Adjust medication and seek specialist treatment e.g. Surgical management biventricular pacing if appropriate

Patient choice regarding place of deathTimeline will be different for all patients depending on deterioration, so regular monitoring by community services clinicians will continue based on needs.

Information

Steps that are based in primary careSteps that are based in acute

Steps that are taken in community servicesDecision making point

Shared decision making with patient

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Palliative Care/End of Life pathway with patient & family/carers. Coordinate My Care record established

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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)

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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.

THE PATIENT WITH ADVANCED DISEASE MAKES A CHOICE FOR COMFORT CARE ONLY, NOT PROGNOSTIC TREATMENT.

THREE ADMISSIONS (into any of the following services - Hospital/ Intermediate Care Beds/Rapid Response Team) WITHIN THE PAST YEAR WITH SYMPTOMS OF HEART FAILURE.

NEW YORK HEART ASSOCIATIONCLASS III OR IV, SHORT OF BREATH AT REST OR ON MINIMAL EXERTION DESPITE MAXIMAL MEDICAL THERAPY.

DIFFICULT PHYSICAL OR PSYCHOLOGICAL SYMPTOMS DESPITE MAXIMAL MEDICAL THERAPY.

WEIGHT LOSS- GREATER THAN 10% WEIGHT LOSS OVER PAST SIX MONTHS.

GENERAL PHYSICAL DECLINE.

SERUM ALBUMIN <25G/L.

CHRONIC KIDNEY DISEASE (eGFR <15ml/min)

PATIENTS WITH STAGE 4 OR 5 KIDNEY DISEASE WHOSE CONDITION IS DETERIORATING OR PATIENTS WHO HAVE DECLINED OR DISCONTINUED DIALYSIS.

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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

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Contact detailsWe are available Monday – Friday, 09.00hrs – 17.00hrsLennard Road Office Telephone: 020 8274 6416 or 6152Fax: 020 8274 6174

Croydon University Hospital Telephone: 020 8401 3000 Ext. 4413Contact via switchboard 020 8401 3000, bleep 772

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Any Questions?