Key Actions for Change
- Identify a leadership team using the PCN CVD Clinical Lead, and an operational clinical team specific to your PCN workforce.
- Support embedding the rapid systematic optimisation of HF (including the 4 pillars of medication) using additional Health Care Practitioners available to your PCN workforce.
- Agree a management process by which all patients will have an up-to-date management plan with optimised care.
Areas of Interest
Areas to consider for all patients:
- Lifestyle management
- Medicines optimisation
- Management plans
- Regular individualised follow-up
- Specialist oversight (MDT sessions) where available and appropriate
- Early Frailty/last year of life identification
- Advance Care Plans
- Patient initiated follow up (PIFU)
- Monitoring role of PCNs
Toolkit Resource 
- NICE NG106 Diagnostic pathway - Overview | Chronic heart failure in adults: diagnosis and management | Guidance | NICE
- HF Management Plan - Excellence in heart failure. Toolkit by Oxford AHSN - PDF Free Download (docplayer.net)
- E-learning education modules - e-lfh.org.uk - programmes - heart-failure-and-heart-valve-disease
- QOF Heart Failure Indicators - NICE - QOFIndicators
- PCN DES contract - NHS England » Network Contract DES
- European Society Cardiology clinical management pathway – 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (escardio.org)
- Pumping Marvellous Care Management Plan - Heart Failure Foundation – Heart Failure Information for Patients (pumpingmarvellous.org)