We will work in partnership with you, your GP, Consultant Cardiologists and the wider cardiology team and any other relevant healthcare professionals to achieve the above. Within the Community Heart Failure Team caseload, your condition may be managed in one of 3 ways:
Heart Failure Titration Clinic
This is a telephone ‘virtual’ clinic for the most clinically stable patients where the team will contact you on a specified day and time to gradually increase your heart failure medications to an optimal dose. In between contacts you will be asked to check your blood pressure and pulse either with your own machine or at your GP practice and have blood tests either with your GP or at your local hospital / community hospital.When you are stable and fully optimised on your medication you will be discharged to open review.
Standard caseload
This is where you will be accepted and assessed if appropriate.
- You will receive a letter and information pack on acceptance to caseload.
- Then an initial telephone assessment. If appropriate, then treatment may be altered or stated at this stage. Basic education about your diagnosis will be given and your questions will be answered.
- You will be followed up either by phone or by face-to-face review at your home. If reviewed at home, you will be physically examined.
- If your condition and symptoms worsen, you may be ‘stepped up’ to the Cardiology Virtual Ward
- Referrals will be made to other services as appropriate.
- When you are stable you may be ‘stepped down’ to the titration Clinic to optimise your medication or alternatively you may be discharged to ‘open review’
Cardiology Virtual Ward
Patients who are more unstable with their symptoms and needing high levels of diuretic therapies or have been discharged from hospital and have an increased risk of readmission may be cared for on the Cardiology Virtual Ward. If you are on the Cardiology Virtual Ward, then:
- You will be contacted more frequently by the team, including at weekends as needed.
- You may be issued with equipment in your home to monitor your blood pressure, pulse, oxygen levels, weight etc. this will be uploaded electronically to the Heart Failure Team so we can more closely monitor your condition and how you are responding to treatment.
- You may be contacted by the Holistic Virtual Ward Team to check blood tests, observations.
- You will be discussed at the regular virtual ward multi-disciplinary team meetings.
When we are happy that your condition has improved enough and that you are more stable, than you may be ‘stepped down’ to the standard heart failure caseload.
Please note that during your time with the Heart Failure Service you may at different times move back and forth through the above caseloads.
STEP UP
Admission avoidance - Preventing a hospital admission for a patient and receiving hospital level support and care in the community.
STEP DOWN
Early discharge - Enabling early discharge from the hospital whilst maintaining hospital level support and care.