Heart failure specialist nurses: managing care in the community

One of the most common causes of hospital admission, heart failure can often have a major effect on the quality of life of patients and their families.

The problemAlliance_Josh Sunkur

Heart failure is a common progressive and distressing condition which can be disabling and life-limiting. It affects around 550,000 people in the UK.

Managing heart failure is challenging as patients are often from an older age group and may require social support.

The majority of this group of patients also have a number of other long-term conditions, requiring multiple medications. This means they may receive treatment from a number of different health professionals, which can result in fragmented care.

Heart Failure Nurse Services

Heart Failure Specialist Nurse services are now well established in many areas of the UK, however some gaps still remain in service provision and staffing levels in certain localities.

For instance, few select Clinical Commissioning Groups are decommissioning heart failure community services due to financial pressures. This has significant health implications for the local population.

The call for change

I work closely with patients and their families to empower them to self-manage their condition and reduce unnecessary hospital admissions.

Josh Sunkur, Community Heart Failure Specialist Nurse

The right pathway, appropriate treatment and support means that survival rates, experience of care and quality of life for many people living with heart failure can dramatically improve.

What we did

We tested an innovative community and home-based heart failure programme led by Heart Failure Specialist Nurses (HFSNs). The Big Lottery Fund funded the 76 Heart Failure Specialist Nurse posts in 26 NHS primary care organisations in England.

We administered the funds, managed and supported nurses and helped shape the roles and services by providing professional development.

  • Between 2004 and 2007 the 76 HFSNs saw approximately 15,000 patients, the majority of whom had at least one home visit. The programme delivered a 35% reduction in all cause admissions and significant cost savings.
  • The evaluation demonstrated that HFSNs based in primary care play a major role in managing and supporting heart failure patients at the critical period post-diagnosis, as well as ongoing integration in primary and secondary care.

You can order or download our CPD-accredited integrated approach to managing heart failure in the community summary booklet, which breaks down the findings of our external evaluations. This includes the proposal, cost savings, and an outline of the challenges facing healthcare professionals caring for people with heart failure in the community.

Evidence for change

Establishing community nurse-led heart failure services and adopting a multi-disciplinary team approach can:

  • Reduce hospital admissions and associated costs
  • Improve quality of care, quality of life and patient experience
  • Support people with heart failure to self-manage their condition
  • Bridge the interface between primary, secondary and tertiary care, facilitating and improving communication channels between GPs and cardiologists to support the integration of patient management
  • Provide a key link professional to identify when other services should be engaged and help their patients access them, for example, cardiac rehabilitation, social care or palliative care
  • Provide education and up-skill generalist primary care teams, enabling them to take over the management of heart failure patients, and encourage a more holistic approach including consideration for psychological and social care needs.

Further information

You can order or download our CPD accredited integrated approach to managing heart failure in the community summary booklet, which breaks down the findings of our external evaluations.

For more background detail about the evaluated services in England download our full Heart Failure Nurse Service evaluation or the executive summary.

You can also find out more in our retrospective evaluation of the role of the BHF Heart Failure Specialist Palliative Care Nurse.

Read more about the range of our evidence based innovative pilot services.

Community Heart Failure Service summary cover SIRHF1


Interested in setting up or integrating your own community based Heart Failure nurse service? Our online Business Case Toolkit resource could help you make your case.