Disclaimer
This process was developed for Penrose Health, and is based on NICE guidelines from June 2023. You must have the appropriate training, use your clinical judgement, and escalate when necessary.
Why we do this review
These reviews are designed to support patients diagnosed with heart failure by checking that they are on track with their current treatment plan, and/or make adjustments to their treatment.
Summary
Heart failure is a condition where the heart can’t pump blood as well as it should. This reduces blood flow (and oxygen transport) to vital organs such as the kidneys and lungs, which can cause severe damage. Heart failure is a serious condition, but its symptoms can be controlled with the right treatment.
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Care pathways
Part of QOF
This pathway is designed to record incidence of patients with Heart Failure and support them to manage their condition.
If a detailed review has already been carried out by a hospital or another healthcare professional, we do not need to recall the patient or carry out the review as described below
1️⃣ Book the appointment
Reception
- We are using a combination of platforms / tools / teams to book patients in correctly with minimal manual effort. If @Louis Williams hasn’t already been in touch, check out the page to find our Monthly Summary plans or reach out to him to find out what you should be doing:
- If we’re using Hippo Labs, log into app.hippolabs.co.uk to find patient lists (see for more information)
- If we’re using Hero Health or AccuRX, @Louis Williams will send your team manual excel recall lists
- Call the patient to book an appointment with an HCA (F2F)
- Advise the patient that they will have a blood test on the day, and that they must produce a fresh urine sample on the day of their appointment
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Always check if the patient requires an interpreter (book double appointment if they do), if there’s anything else pending in the pink QOF box that we can address while we’re speaking with the patient, and that their contact details are correct
2️⃣ Patient arrives for appointment
Reception
- Record that the patient has arrived in the appointment book
- Allow the patient a moment to relax before asking to capture data on height, weight, blood pressure, smoking status, and alcohol status (if possible) and add to patient’s EMIS record
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3️⃣ Carry out review
HCA (F2F)
- Open the clinical template ‘Penrose Health - Heart Failure’ on EMIS
- Draw bloods (for HbA1c, FBC, cholesterol, U&E, eGFR) and take a urine sample (for urinalysis)
- Complete pg. 1 (’HCA Review’) of the clinical template
- Provide lifestyle advice and/or advice on reducing alcohol intake, as appropriate
- Make relevant referrals
- Offer flu and pneumococcal vaccination, if appropriate
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Tell the patient that they’ll be contacted with their test results. Alternatively, patients can check results themselves via Patient Access & the NHS App
4️⃣ Check & triage results
Lab Reports Team
- Review pathology results, and action as per the Lab Reports (Path Links) page. If, according to this page, a follow-up appointment is required, progress to step 5 below.
5️⃣ Follow-up appointment for moderate or high risk patients
Pharmacist or GP (F2F or remote)
- Open the clinical template ‘Penrose Health - Heart Failure’ on EMIS, and complete pg. 2-5
- If blood pressure measurements are off-target according to the Hypertension Guidance for Primary Care in South East London, a follow-up will be needed as this could be an indicator of Hypertension
- If HbA1c measurements are off-target, a follow-up will be needed as this could be an indicator of Pre-diabetes or Diabetes
- Schedule a 6-month review
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Resources for patient info/referral
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