Integrated tailored care: addressing heart failure comorbidities in the UK

The challenge

In the UK, it is estimated that heart failure affects over 920,000 people – nearly 80% of this group also lives with three or more coexisting health conditions.¹ Common comorbidities are often non-cardiovascular, such as diabetes, chronic obstructive pulmonary disease, chronic kidney disease and asthma.^{2 3} People living with three or more comorbidities lose up to five times more life years.³ In addition to being a common cause of hospitalisation,^{1 4-6} comorbidities also increase healthcare costs and impact quality of life.^{4 7} Worse outcomes may be the result of polypharmacy, a common occurrence where a person uses five or more medications.⁸

The 2021 European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure state that optimal care requires a tailored and comprehensive approach.⁹ Multidisciplinary teams should not only manage heart failure, but all comorbidities. However, the ESC does not provide detailed guidance on the composition or organisation of such a team. Clearly defined guidelines are needed to ensure better outcomes for people living with heart failure.¹⁰

The solution

In January 2020, a new initiative was launched by Liverpool University Hospitals NHS Foundation Trust to provide tailored and comprehensive care for people with heart failure and comorbidities. This multi-specialty, multidisciplinary team is the first of its kind, integrating primary, secondary and tertiary care to manage comorbidities.¹¹ It comprises cardiologists and nurses who specialise in heart failure and work alongside a variety of experts, including specialists in kidney disease, pharmacy and palliative care.¹¹

The team meets virtually once a month to discuss and provide consensus-based recommendations for people who have been referred to the service. As of May 2022, 30 people have been referred by community heart failure teams, hospital-based heart failure teams (secondary and tertiary care) and other specialty teams.^{11 12} In preparation for the meetings, individual patients are consulted and details of each person’s case are shared with the team to discuss any preliminary questions.¹²

Discussions are tailored around the needs of each individual, and recommendations may involve the following:¹¹

• Improving heart failure treatment, including the optimisation of therapy, medication compliance and deprescription of medications to avoid the burden of polypharmacy.
• Assessing comorbidities, such as cardiorenal metabolic status, chronic respiratory pathologies, falls risk and cognitive dysfunction.
• Facilitating referrals to other services; for example, referring to device therapy, and transplant and dialysis assessment.
• Advance care planning, including referral to community palliative care, hospice admission and device deactivation.

Recommendations are recorded in electronic health records, which are shared with primary care services and hospitals, and sent back to the heart failure care team that made the referral.¹¹

What has been achieved?

The team is a tailored, cost-effective care model that addresses comorbidities in people living with heart failure, thereby improving outcomes and reducing healthcare costs.¹¹

The initiative secured funding from the Liverpool Single Services Cardio-Respiratory Operations Group (from Liverpool Clinical Commissioning Group) by submitting a business case.¹² Dr Rajiv Sankaranarayanan, Heart Failure Clinical Lead and Consultant Cardiologist at the trust, and his team used data and patient stories from a small multidisciplinary pilot to make the case for a multi-specialty, multidisciplinary team.¹³

An observational assessment of the initiative has shown that people who were referred to the service experienced a reduction in hospital admissions and outpatient appointments, compared with the period before introducing the multi-specialty, multidisciplinary team.¹¹ Although further research is needed, this study showed the initiative’s potential to reduce healthcare costs, and save time and travel for participants. In addition, the initiative can address polypharmacy and reduce the number of specialist appointments that people with heart failure need to attend.^{11 12}

During the COVID-19 pandemic, the team continued to meet virtually.¹⁴ This enabled patients to receive consensus-based recommendations without having to attend face-to-face appointments at different outpatient clinics. The team facilitates significant collaboration among a network of specialists, who are dedicated to optimising care for people living with heart failure and multiple comorbidities.¹¹

The initiative currently comprises 25 people, and has gained national recognition from the heart failure community.¹² In 2021, it was nominated for two HSJ Awards (a platform that highlights healthcare service excellence in the UK): Cardiovascular Care Initiative of the Year and Value Pilot Project of the Year.^15-17

Next steps

In addition to referrals from hospitals, the team will soon allow general practitioners (GPs) to refer people with heart failure and comorbidities directly. GPs will also be able to attend the monthly meetings.¹²

This initiative is receiving greater recognition from other hospitals across the UK, which aim to adopt this care model.¹² Although some areas in the country do not have as many specialists available, they are working on adapting the meetings to cater to local resources. The team has also engaged patient advocates, who want to ensure access to this care model in their area.¹²