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Key Actions for Change

  1. Ensure Annual Review incudes as a minimum: NHYA coding, assessment for the presence of frailty or patient being in the last year of life, lifestyle management, medication optimisation, co-morbidity optimisation, education, review of frailty/being in the last year of life, the offer of cardiac rehabilitation to patients with HF, and physical examination.
  2. Educate the Clinical Team on the value of cardiac rehabilitation – include it within the HF annual review template for your PCN.
  3. Ensure patients who attend cardiac rehabilitation are coded in the GP system.


Areas of Interest

Areas to consider for all patients:

  • Monitoring role of primary care as outlined in NICE NG106 and facilitated by QOF HF indicator. Pathways facilitating communication between patient/primary care/HF specialist services are essential. These include advice and guidance, rapid access for deteriorating patients such as access to virtual wards and day units. Primary care has an important monitoring role following initial optimisation of care which ideally has been undertaken by the HF Specialist MDT.
  • Access to Cardiac Rehabilitation - has an important role to play in supporting HF patients
  • PIFU- Patient Initiated Follow up Care is an NHSE/I initiative which has particular relevance to HF
  • HF 6 month/Annual review - NICE recommend a 6 monthly review; QOF HF indicator is based on annual review. Routine reviews present opportunity to assess symptoms and confirm evidence-based treatment is optimised, noting that patients with frailty/those in the last year of life need a personalised approach. Where there are concerns that specialist review is indicated (suggestion of decompensation or where further optimisation of therapy should be considered) then seeking advice with timely reengagement with specialist services should be considered to avoid acute admission to secondary care

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