Case study from Heart failure policy and practice in Europe

Comprehensive heart failure care in the Barcelona Litoral Mar Integrated Health Area

17 November, 2020

The heart failure management programme of the Barcelona Litoral Mar Integrated Health Area was introduced in 2005 and spans hospital and community settings.1

Under the programme, when people with heart failure are admitted to hospital they are seen by a cardiologist, who establishes the cause of heart failure and an appropriate treatment plan. Heart failure specialist nurses provide therapeutic education and assess the patient’s cognitive, social, functional and frailty-related skills and needs.2

Members of the hospital care team meet with primary care nurses on a weekly basis to coordinate care and discuss people being discharged from hospital.2 All patients have a follow-up appointment with their heart failure care team within seven days of hospital discharge, with an option for home visits if needed. After that, people living with heart failure have access to home-based follow-up with primary care nurses or a combination of home- and hospital-based follow-up led by heart failure specialist nurses.2

The Barcelona Litoral Mar Integrated Health Area also has outpatient heart failure units (day hospitals), primary care emergency centres and social care resources (e.g. palliative care units) to support seamless care transitions and reduce risk of readmission following hospitalisation for heart failure.2 The model has reduced hospital admissions and improved survival in people living with heart failure.1 2


  1. Comín-Colet J, Verdu-Rotellar J, Vela E, et al. 2014. Efficacy of an integrated hospital-primary care program for heart failure: a population-based analysis of 56,742 patients. Revista Española de Cardiologia (English edition) 67(4): 283-93
  2. Comín-Colet J, Enjuanes C, Lupón J, et al. 2016. Transitions of care between acute and chronic heart failure: critical steps in the design of a multidisciplinary care model for the prevention of rehospitalization. Revista Española de Cardiología (English Edition) 69(10): 951-61
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