The challenge

Ceredigion Community Heart Failure team provides holistic support to the increasing number of people with long term heart conditions in the region. The pandemic meant it was unsafe to deliver face-to-face clinics for the titration of medication for new heart failure patients, and so the team needed to find alternative ways of providing care.

What we did

Ceredigion Community Heart Failure team, Delta Wellbeing, Hywel Dda University Health Board and Tunstall Healthcare worked together to deliver a telehealth (remote patient monitoring) package to support Heart Failure patients in their own homes.

Patients are enrolled onto service by Health Care Support Worker (HCSW), and Llesiant Delta Wellbeing arrange system installation and training directly with patients. Patients take their own vital signs readings, such as blood pressure, weight and pulse oximetry each Monday ahead of attending a TECH clinic the next day. All readings are reviewed and managed remotely by healthcare professional, and any abnormal readings or messages from patients are responded to outside of clinics.

Tunstall provided comprehensive, specialist training for the Heart Failure Team, contributing to pathway planning and ensuring a smooth transition to the new model of care. A range of materials were also created to support patients in learning about the service, as well as them being given a tutorial on how to use the equipment at the point of installation.

"Any delay in initiating treatment can result in preventable death, harm and hospitalisation.

Telehealth has delivered benefits throughout the pandemic and beyond by enabling us to dramatically shorten the time it takes for us to optimise heart failure therapy for patients, avoiding hospital admissions and improving outcomes."

Clare Marshall, Heart Failure Nurse, Hywel Dda University Health Board

One Stop Clinics

In addition to the standard telehealth heart failure clinic, One Stop weekly clinics have also been introduced, which prioritise patients according to their NTproBNP (diagnostic screening tool to differentiate between patients with normal and reduced left ventricular systolic function).

• Four patients per session
• Transthoracic Echocardiogram + ECG
• Clinical Assessment by Specialist Pharmacist
• Referred to ‘follow up’ Heart Failure Clinics
• Delivered across the Hywel Dda Health Board region: Pembrokeshire, Carmarthenshire, Llanelli, Ceredigion

Results

Principles behind rapid optimisation:

• B-blockers, ARNI, SGLT2i and MRA act as diseasemodifying agents and should be considered foundation therapy
• The magnitude of treatment benefit of each drug class is independent of that of the others.
• There is early morbidity and mortality benefit of each foundation drug within 30 days
• Delay in initiation results in preventable death, harm and hospitalisation
• Start and titrate drugs in parallel as far as possible
• Initiation of a new drug at low dose is probably better than titrating an existing drug to maximum dose
• Adapt to each patient depending on heart rate, blood pressure, renal function, fluid status and weight
• Review frequently with appropriate information; at least daily as inpatients, every one or two weeks as outpatient
• Minimise the total number of visits and echocardiograms
• Aim for optimal therapy as soon as clinically possible

"Myself and my wife cannot speak more highly of the attention to detail and professionalism shown during my care.

We have both felt very confident in all that they have done and said. I could not be happier with the care I have received. They are both friendly and always have time to explain things and to answer my questions.

Thanks for everything. I can’t praise the service enough. They go far and above their duties. I would just like to say a huge thank you."

Patient

Outcomes

• Across both the standard and one-stop Heart Failure clinics, more than 100 patients have used the service (as of September 2023).
• Average time for Heart Failure Therapy optimisation prior to One Stop was 63 weeks, compared to 7.4 weeks through the use of telehealth.
• Patients report improved self management and resulting health improvements, including admission avoidance.
• Patients and carers benefit from reduced stress and cost associated with travelling to hospital and parking.
• Hywel Dda covers a rural area, and remote health monitoring therefore helps to improve access to care
  due to the decreased need for travel.
• Telehealth has enabled a more multi-disciplinary approach, as the system enables multiple professionals
  to view objective data.
• Post pandemic, the service has evolved to monitor symptom management as well as medication titration.
  The service supports a more standardised approach, at the same time being more resource-effective.