Nurse-led, Home-based Management of Chronic Heart Failure

Patients with heart failure account for about 5% of acute medical admissions to hospital and 10% of bed occupancy.¹ Intervention by a specialist nurse can substantially reduce the risk of readmission to hospital for heart failure.² Nurse leadership of such programmes has also been successful in terms of reduced hospital admission rates, improved quality of life and cost savings.³

Both models of care principally rely on the appointment of a specialist heart failure nurse to provide health care designed to optimize drug therapy, promote self-care (e.g. fluid and dietary management), provide a means for early detection of clinical deterioration and apply more appropriate follow-up according to the needs of each patient.⁴

• Clinic-based service:
  • Involves the establishment of a specific heart failure clinic that is usually situated in the hospital outpatient department.
  • Follow up after hospitalisation at a nurse-led heart failure clinic can improve survival and self-care behaviour in patients with heart failure as well as reduce the number of events, readmissions and days in hospital.⁵
  • This model has proven to be less effective than home-based intervention but has the potential to reduce all-cause hospital readmissions and associated hospital bed utilisation.⁴
• Home-based service:
  • Has proven to be the most consistent and effective strategy in reducing heart failure and all-cause hospital readmissions in typically older heart failure patients.
  • This model appears to have an even greater effect on associated hospital bed utilisation by reducing days of readmission by up to 60% relative to usual care.⁴
  • The beneficial effects of a multidisciplinary home-based programme for the management of patients with chronic heart failure in reducing frequency of unplanned readmissions persist in the long term and are associated with prolongation of survival.⁶
• Hybrid service:
  • Comprising home plus clinic-based follow-up.

• Qualified specialist nurse who is able to work as an autonomous practitioner.
• Regular follow-up and assessment, including blood chemistry, to detect early clinical deterioration.
• Continued adjustment and optimisation of therapy according to agreed protocols.
• Promotion and support of self-management, including daily monitoring of weight.
• Education: including both pharmacological and non-pharmacological aspects of care, including exercise and nutrition advice.
• To act as an intermediary between the patient and other professionals, e.g. cardiologists and the primary health care team.
• Provide support for patients and their carers.