Meeting the needs of people living with heart failure through cardiac rehabilitation and a community heart failure hub

Aneurin Bevan University Health Board

There is a strong body of evidence showing that cardiac rehabilitation for heart failure patients improves quality of life. However, within Aneurin Bevan UHB, less than 4% of patients with heart failure accessed cardiac rehabilitation.

A project was initiated to develop a rehabilitation service that was responsive to patient needs and provided prompt optimisation of medication within community, with a view that this would also free capacity of specialist teams to respond to more complex patient needs. A stakeholder group was established, consisting of a primary care clinician, cardiologist, managers, heart failure staff, cardiac rehabilitation staff, Value based health care team and the YMCA manager.

Through a series of Plan-Do-Study-Act cycles, key members of staff were identified to triage patients referred to service depending on clinical and patient need, a Heart Failure nurse specialist attended rehab classes and provided a drop-in service for patients as required, and revised documentation was developed to support patients taking responsibility for self-management of symptoms.

Patients attending rehabilitation have all had an improvement in exercise ability, irrespective of their starting point, and all have seen an improvement in quality of life, reporting a reduction in anxiety and depression scores. There has been improved staff morale through being able to deliver effective patient care in a timely manner. Optimisation of medication was achieved on average in 15 weeks by the Heart Failure Hub and cardiac rehabilitation, compared to 28 weeks in usual secondary care.

Funding has been secured to continue the service in Caerphilly borough, with a business case submitted to replicate in other boroughs. Each rehab team will continue to work closely with a heart failure specialist to implement this service in their communities.

Linda Edmunds

linda.edmunds2@wales.nhs.uk