The North and South division Heart Failure Specialist Nursing Service provides support and treatment to patients with a diagnosis of heart failure. This includes patients in which the mechanism of heart failure is due to left ventricular systolic dysfunction, as well as the management of patients with HFPEF / diastolic dysfunction, who have been seen by a cardiologist and who have a management plan in place. (North Service only)
This includes providing nurse led clinics, as well as domiciliary visits to house bound patients. The involvement of the Heart Failure Specialist Nurse may be for a short period following diagnosis and to ensure appropriate medical management of the condition, or may be for a longer period for patients experiencing complex symptoms.
Services provided by the team include:
- Medical titration
- Complex symptom management
- Non oral diuretics in the community (IV/SC diuretics) - (North division only)
- Palliative care support in conjunction with specialist palliative care services and district nurses
- Patient/carer education and psycho-social support
- Escalation of complex patient cases to the cardiology MDT
- Teaching and support to colleagues within the community around the management of chronic heart failure
- Cardiac Rehab - (South East Staffs service only)
Smart with your heart – listening to the message from heart failure patients
Smart with your heart is a pilot project which aims to help reduce the number of people with chronic long term heart failure from being readmitted to hospital.
Up to 70 per cent of people leaving hospital with heart failure are admitted to hospital again within 12 months of going home. This can be due to people gradually becoming more unwell at home and then being unsure of what help is available.
The project will see 300 people recruited to use three digital services to help them understand and manage their own condition with confidence. The pilot will run until 1 January 2020.
University Hospitals of North Midlands NHS Trust (UHNM) and Midlands Partnership NHS Foundation Trust, including the community heart failure team, are working in partnership with digital companies, using their new, commercially available technology to run the pilot.
The first digital service will enable patients to respond to text messages asking how they are feeling compared to their last text message (same, better or worse) and these responses will be recorded by a telehealth co-ordinator.
By doing this, patients will be more closely monitored and will be able to more smoothly access care in the community, should they need it, before they become acutely unwell, reducing the need to return to hospital.
The second digital service will give patients exclusive access to an online health library to help them improve their own self-care behaviours.
The third digital service will refer patients to trusted third sector or voluntary sector organisations, such as bereavement counselling or citizens advice or to offer patients opportunities to engage in community groups and activities such as dance classes, allotment working or walking groups.
The wellbeing of patients and improvements in their quality of life through social prescribing can help reduce GP attendances and improve patients' general physical health.
Information for patients
Patients taking part will be given access to an online account with Recap Health to enable them to access educational information designed and approved specifically for the individual.
Videos, leaflets and webpages will be available for patients to download with the option to be able to send feedback about the content or request additional information. Patients will also be set up on 'Florence' which is an interactive text phone service and is checked weekly. A member of the team will contact a patient if they respond to the text message that they are not feeling as well as they were.
There are a number of organisations who provide support in the community and can help people with any problems that patients may be experiencing as a result of heart failure. These include anxiety, depression, housing and finances. A referral can be made if necessary to a digital tool called 'I Navigator' for patients to find additional support in these areas.
In order to take part, patients will need:
- A mobile phone that can send and receive text messages
- An email address
- To be able to read and text in English (or have a carer who will do this on your behalf)
- To live in the North Staffordshire area
Those wishing to take part will in the pilot will be put in contact with a Telehealth Co-ordinator who will explain in more detail what is involved including how to set up 'Florence' and the Recap Health Digital Library. You will also be given the opportunity to ask questions.
Patients will be required to be part of the project for a maximum of three months, however, you can stop being part of the project at any stage you may wish.
Your care will not be affected in anyway by not taking part in the project.
Read this leaflet to find out more: Smart with Your Heart Patient Information Leaflet (pdf).