We are a team of specialist nurses and paramedics, working within Lincolnshire Community Health Services. We are an extremely experienced team who come from a variety of backgrounds including Coronary Care and Intensive Care Units, acute medicine, cardiac rehabilitation, community nursing and the ambulance service. Most of the team are independent prescribers and are trained in all areas of cardiology with specialist training in heart failure and clinical assessment often up to Masters degree level.

 We provide care for patients who are diagnosed with chronic heart failure who meet the following criteria:

  • Recent hospital admission for worsening heart failure symptoms.
  • Newly diagnosed with chronic heart failure with high risk of readmission to hospital.
  • Unstable clinical condition in community setting, indicated by need for recent increase in water tablets, with high risk of admission.

Patients we do not see are:

  • Patients unwilling to have nurse-led care.
  • Other immediately life-threatening illness.
  • Patients who have had a heart attack within the previous 8 weeks unless accepted following discussion with a consultant cardiologist or cardiac rehabilitation specialist nurse.
  • Patients registered with GPs outside the Lincolnshire area.
  • If the underlying cause of heart failure non-cardiac e.g. respiratory.

The aim of the team is to:

  • Improve quality of life by managing patients' healthcare needs in their own homes. We also hope it will mean people can avoid having to make unnecessary hospital visits.
  • Stabilise and improve your symptoms.
  • Slow down deterioration of the condition.
  • Ensure you are on the most appropriate, evidence-based heart failure medications at the best tolerated doses. The 4 pillars of heart failure (see section on medication).
  • Carry out assessments and develop treatment plans with patients and their carers and families and other professionals.
  • Ensure you are referred onward to appropriate and relevant clinicians / services to further manage your condition or improve your quality of life, e.g. Cardiac
  • Rehabilitation for lifestyle advice and exercise support, cardiologists re further specialist investigations, pacemakers etc.
  • Work in collaboration with palliative services (Macmillan, St Barnabas Hospice, Marie Curie etc) in cases where the condition is considered palliative or end of life to promote comfort of symptoms and ensure patients wishes are met via Respect documentation.
  • When your condition is stabilised, and your medication is optimised then we will discharge you from the caseload with the option to self-refer yourself directly back to the team should you develop heart failure symptoms in the future.