Heart Failure Care Plan

Key objectives

To reduce A&E admissions and educate 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 travelling large distances, where the follow-ups aren’t being efficiently or effectively managed. When the patient cohort completed a survey about heart failure, a high 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.

Heart Failure Care Plan Template

The 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 HTML

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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 education and tailoring of your medications.</p>

<p>The aims are to initiate the correct treatment for your individual condition and over time ensure you are on the correct medications and dosages to provide you with protection from getting worse 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>Once your medications have been maximised your echocardiogram will be repeated to see if there has been any recovery to your heart function. If there has, you will not need routine heart failure team follow up and you will discharged back to your GP. If there has been no improvement your in your heart and symptoms are still troublesome, your case will be discussed at an MDT meeting, a meeting attended by other health professionals including cardiologists. There are some more advanced therapies that you might be suitable for that may further improve your heart and symptoms.</p>

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

<ul>

<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. Please ask your specialist to refer you, if you feel you need more guidance on staying active</li>

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

<p>Please add your <a href="/diagnoses/viewDiagnoses.action" target="_blank">Diagnosis here</a></p>

<p>Please add any <a href="/allergies/viewAllergies.action" target="_blank">Allergies</a> you may have</p>

<p>Please keep your medications updated, you can do that in your record <a href="/auth/manageMedications.action?tab=treatments" target="_blank">here</a></p>

</div>

<h2>What is Heart failure </h2>

<table>

<tr>

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

</tr>

<tr>

<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>

</tr>

<tr>

<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>

</tr>

<tr>

<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>

<tr>

<td><strong>PKB Heart Failure team Library </strong> You can view the Library resource from your team </td>

<td><a href="/library/manageLibrary.action" target="_blank">Please click here</a></td>

</tr>

</table>

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

<label for="classI">Class I</label>

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

</div>

<label for="classII">Class II</label>

</div>

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

</div>

<label for="classIII">Class III</label>

</div>

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

</div>

<label for="classIV">Class IV</label>

</div>

<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>

</div>