Heart Failure Care Plan

Key objectives

To reduce A&E admissions and educated patients on their heart failure.


Outcome measures

Equip every patient in the Heart Failure Team (HFT) with the information and advice to support the self management of their heart failure. Educating them and giving them an escalation plan to follow when needed.


Current Baselines

All activity is face to face, with a lot of patients traveling large distances, where the follow-ups aren’t being efficiently or effectively managed. When the patient cohort was survived, a number of patients reported not knowing they had Heart failure.


Workflow

Patients are given the Heart Failure care plan by the HFT at their appointment with the team or patients can add the care plan when they get added to the HFT. Within the care plan, patients track their symptoms related to their heart failure, it contains advice and videos and an escalation plan for support for when it’s needed. The care plan is then reviewed by the HFT at their next appointment.


Patient - register - care plan added by Heart Failure Team - Patient tracks symptoms - symptoms review in next appointment with the Heart Failure Team.

Heart Failure Care Plan Template

Th Heart Failure care plan makes brilliant uses of every aspect of a PKB care plan functionality,


  • Information and advice

  • Url links to websites

  • Patient-friendly video

  • Patient disease classification

  • Symptoms to monitor

  • Measurements to track

  • RAG escalation plan

Example care plan template code for Heart Failure Care Plan

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<p>As a patient diagnosed with heart failure you will be reviewed and monitored by the heart failure specialist team for a period of time.</p>

<p>The aims of your management are to initiate the correct medical management for your individual condition and over time ensure you are on the correct medications and dosages to provide you with the protection they provide and hopefully some symptom relief. During this time your heart failure specialist will also monitor your condition and check for any adverse side effects.</p>

<p>You may also benefit from some other treatments that have been proven to benefit heart failure patients and your specialist will consider these when it is appropriate.</p>

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<p><b>Heart Failure specialist's responsibilities:</b></p>

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<li style="list-style:inherit">Explain your diagnosis clearly and provide literature and advice</li>

<li style="list-style:inherit">Provide contact details and instructions of what you should monitor and when to get in touch with the HF specialist team</li>

<li style="list-style:inherit">Commence appropriate medical therapy for your particular heart condition</li>

<li style="list-style:inherit">Monitor effects and try to increase dosages over time to recommended levels to provide you with the most protection</li>

<li style="list-style:inherit">Adjust other medications to provide relief of your symptoms where possible</li>

<li style="list-style:inherit">Consider non-medical treatments that you may benefit from once on optimal medications</li>

<li style="list-style:inherit">Consider referral to the cardiac rehabilitation programme</li>

<li style="list-style:inherit">Consider referral to Increasing Access to Psychological Therapy's (IAPT)</li>

</ul>

<p><b>Recommendations to patients:</b></p>

<ul>

<li style="list-style:inherit">Take your medications as prescribed. If you think any of your tablets are disagreeing with you please inform your specialist or GP who can investigate.</li>

<li style="list-style:inherit">Weigh yourself daily. It is important to monitor your weight and if an increased weight gain of 2kgs over 3 days we recommend you contact your heart failure specialist for advice.</li>

<li style="list-style:inherit">If you notice any worsening breathlessness, leg swelling or reduced exercise tolerance contact our heart failure specialist for advice.</li>

<li style="list-style:inherit">Don't smoke.</li>

<li style="list-style:inherit">Try to be as active as is safely possible. If you need any assistance with this the cardiac rehabilitation service may support you.</li>

<li style="list-style:inherit">Eat a varied healthy diet. If unsure the dietician can offer advice from the cardiac rehab team.</li>

</ul>

<p>This care plan is to help you and your family self manage your heart failure. You can use this plan as your online resource folder. You can access online links, watch a video from British Heart Foundation and also track symptoms. </p>

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<h2>What is Heart failure </h2>

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<th colspan="2">Useful information</th>

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<td><strong>British Heart Foundation:</strong> If you have been diagnosed with a condition, or know someone who has, we have reliable information to help. You can also join our online community on HealthUnlocked and connect with people like you</td>

<td><a href="https://www.bhf.org.uk/" target="_blank">https://www.bhf.org.uk/</a></td>

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<td><strong>HealthUnlocked</strong> HealthUnlocked is the Social Network for Health. Are you looking for answers to your health concerns? There are others who've been there before.</td>

<td><a href="https://healthunlocked.com/" target="_blank">https://healthunlocked.com/</a></td>

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<td><strong>Pumping Marvellous </strong> The Pumping Marvellous Foundation is the UK's Heart Failure Charity</td>

<td><a href="https://pumpingmarvellous.org/" target="_blank">https://pumpingmarvellous.org/</a></td>

</tr>

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<td><strong>Coordinate My Care (CMC) </strong> is an innovative NHS service that records your wishes about your future care, and then shares them, electronically, with all the medical professionals who will be involved. You can now create your own CMC plan, online. You can stop and start, whenever you like, saving details as you go. Once you've filled in all the details, simply book a CMC appointment with your GP or specialist nurse, and they will add clinical details and upload your plan to the CMC system.</td>

<td><a href="https://www.coordinatemycare.co.uk/mycmc/" target="_blank">https://www.coordinatemycare.co.uk/mycmc/</a></td>

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<h2>New York Heart Association (NYHA) classification</h2>

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<input class="form-check-input" type="checkbox" value="classI" name="classI"> Class I</input>

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<p>No limitation of physical activity. Ordinary physical activity does not cause undue breathlessness, fatigue, or palpitations</p>

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<input class="form-check-input" type="checkbox" value="classII" name="classII"> Class II</input>

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<p>Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.</p>

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<input class="form-check-input" type="checkbox" value="classIII" name="classIII"> Class III</input>

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<p>Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.</p>

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<input class="form-check-input" type="checkbox" value="classIV" name="classIV"> Class IV</input>

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<p>Unable to carry on any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased.</p>

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