Improving palliative care for heart failure patients

Bwrdd Iechyd Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board

Improving palliative care for heart Bwrdd Iechyd Prifysgol failure patients Cwm Taf University Health Board

Bwrdd Iechyd Prifysgol Cardiff & Vale University Health Hywel Dda Board has implemented a service for University Health Board heart failure patients to optimise the care they receive towards the end of their lives. This work received the Iechyd Cyhoeddus MediWales award for Innovation Cymru within NHS Wales, which recognises Public Health Wales NHS staff who have introduced an innovation within their area that demonstrates improved patient Ymddiriedolaeth GIG outcomes, improved patient experience Gwasanaethau Ambiwlans Cymru Welsh Ambulance Services and/or improved resource efficiency. NHS Trust

Heart failure is an increasingly common and expensive chronic disease. Although the majority of patients wish to be cared for (and ultimately die) at home, many end up dying in hospital, often after prolonged admissions.

Although palliative care can improve quality of life and reduce readmission rates for these patients, several factors contribute to poor referral rates including: uncertainty around the best time to refer, issues with referring patients who have longstanding relationships with invasive cardiac services, difficulty for palliative care services to match the unpredictable disease trajectory of heart failure, and uncertainty as to whether patients may still benefit from active treatments.

Cardiff & Vale University Health Board has established a transitional crossboundary Supportive Care Pathway for heart failure patients in their last 1-2 years of life. The supportive care team meet on a weekly basis through multidisciplinary meetings and hold co-speciality clinics, where patients can see both cardiology and palliative care specialists simultaneously.

Flexibility in approach is driven by patient rather than service need, with patients being seen in various settings such as the acute hospital, outpatient clinics, at home, in nursing homes or in hospices. Patients are supported to understand the nature of their condition and are gradually transitioned to a more planned palliative approach. The health board has also implemented the use of subcutaneous furosemide infusions in order to alleviate fluid overload in patient homes.

Since launching the service for heart failure patients, death at home (the preferred place of death) has significantly increased and many hospital bed days have been avoided. A majority of the patients reported better symptom control and said they would recommend the service to other patients in their position. This model of care allows patients with a life-limiting prognosis to be seen in individualised settings, thus facilitating a tailored and responsive approach to the unpredictable disease trajectory, which traditional palliative care services have been unable to meet. The emphasis on transitioning between specialties with overlapping input enables earlier referral, transfer of trusting relationships between patients and specialties, and the ability to maintain access to the skills and expertise of both specialties.

The model is also highly sustainable, as the cost savings approximate to £10K per advanced heart failure patient referral. With widespread upscaling across Wales, around 2,100 advanced heart failure patients would potentially be appropriate for referral per year, equating to around £21 million annual cost savings. It could even be applied to other chronic advanced conditions such as end stage renal, respiratory and liver disease.