Integrated heart failure care: expanding a nurse-led programme in Spain

The challenge

Heart failure poses a considerable challenge to the long-term sustainability and resilience of the Spanish health system. It is a common syndrome, with an estimated national prevalence of at least 5%.¹ Between 2015 and 2019, its direct and indirect cost reached an estimated €15,373 per person – and more than half of this figure was attributable to hospitalisations.² Among people over the age of 65, hospitalisations for heart failure increased by 26% between 2003 and 2011.¹

In Catalonia, the rate of hospital readmission with heart failure is high – approximately one in three people is readmitted within six months of discharge.³ In 2012, the mortality rate for heart failure was 14%, rising to 24% in people who had recently been hospitalised.⁴ Experts report that limited communication between healthcare professionals in community and hospital settings is a major issue in heart failure services.⁵

The response

In 2005, healthcare professionals from the Hospital del Mar Heart Failure Unit in Barcelona, with support from the Catalan Health Service, introduced an integrated nurse-led management programme for people living with heart failure.⁶ The programme aims to improve quality of life and reduce hospital readmissions and mortality. It focuses on transitions of care, particularly between hospital and community settings.⁶

The programme follows recommendations set out in a consensus document developed by local heart failure champions, including hospital, primary care and social care professionals.⁶ The document outlines an integrated clinical pathway and governance structure, and delineates the responsibilities of different healthcare professionals, highlighting where and how these may shift throughout the patient care journey.

The programme includes several elements:^{6 7}

• Hospital care: cardiologists establish or review the cause of heart failure and develop a management plan. Heart failure nurses assess people’s mental health, social support and home environment. They also provide therapeutic education and coordinate with other services, such as cardiac rehabilitation and physiotherapy.
• Discharge planning: case manager nurses in primary care attend weekly meetings with the hospital care team to coordinate the discharge process.
• Early review after discharge: people have an in-person or remote follow-up appointment with their hospital care team within seven days of discharge.
• Structured follow-up care: people with complex care needs continue to see hospital-based heart failure nurses via outpatient clinics, home visits or telemedicine approaches. Others are discharged to primary care, where case manager nurses lead home visits, telephone consultations and primary care clinics.
• Other services: the hospital care team works closely with other essential services, including advanced heart failure units and palliative care.

What has been achieved?

The programme was introduced in the Barcelona Litoral Mar Integrated Health Area in 2005 and became fully operational two years later.⁷ Between 2008 and 2011, it reduced the risk of hospital readmission with heart failure by 18%, and of mortality by 12%. The use of remote monitoring devices and video consultations reduced healthcare costs by more than €3,546 per person over the course of six months.⁸

The healthcare professionals involved in the programme developed several peer-reviewed publications and circulated their findings to colleagues, including healthcare professionals and hospital directors.⁵ The findings were relayed to policymakers working on the Health Plan for Catalonia, which led to the prioritisation of integrated care models for heart failure in regional health policy.^{5 9}

Primary care and hospital managers have led the expansion of the programme to the South Metropolitan Barcelona Area.^{5 10} The programme has also been adopted by other centres, including the Puerta de Hierro Majadahonda University Hospital in Madrid. Healthcare professionals wishing to emulate the programme can join a dedicated training scheme to shadow the care teams in Barcelona.⁵

Next steps

An evaluation of the programme in the South Metropolitan Barcelona Area is underway, with results expected by the end of 2021.⁵ Interim findings suggest substantial reductions in preventable hospitalisations and mortality.

The team behind the programme has secured funding from the Catalan Ministry of Health to run a three-year digital transformation project.⁵ The project aims to build the integrated heart failure care model into electronic health records, including prompts for healthcare professionals, measures of care quality and patient experience, and a dedicated platform for remote monitoring and virtual consultations. With these digital solutions, the team hopes to support the implementation of the programme across the rest of Catalonia.⁵