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Development of a transitional cross-boundary supportive care service for advanced heart failure patients


Clea Atkinson

Velindre Nhs Trust, GB
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Heart failure (HF) is an increasingly common and expensive chronic disease. Whilst the majority of patients wish to be cared for (and die) at home, many (~80%) die in hospital during a protracted admission. Although palliative care (PC) can improve quality of life and reduce readmission rates for these patients, several factors including: 1) uncertainty as to the best time to refer, 2) difficulty referring patients who have longstanding relationships with invasive cardiac services, 3) difficulty for PC services to match the unpredictable disease trajectory of heart failure, and 4) uncertainty regarding whether patients may still receive benefit from active treatments, have been shown to contribute to poor referral rates.


To help address some of these issues a transitional cross-boundary Supportive Care Pathway was established consisting of a co-speciality team including a palliative care consultant, consultant cardiologist, and specialist palliative care and heart failure nurses. The team meet on a weekly basis through multi-disciplinary team meetings and joint clinics and integrate with multiple other providers including inpatient ward teams, district nursing teams, GPs, community palliative care teams and hospice teams.

This model allows patients with estimated prognosis of 1-2 years to be seen in individualised settings including; the acute hospital, outpatient clinics, at home, in nursing homes, or hospice thus facilitating a tailored and responsive approach to the unpredictable disease trajectory. The emphasis on transitioning between specialities with overlapping input allows for earlier referral, transfer of trusting relationships between patients and specialities, and the ability to maintain access to the skills and expertise of both specialities.

The innovative elements of this work have been the co-speciality integrated clinics with patients seeing both specialities simultaneously, the cross-boundary approach fitting patient need rather than service need and the introduction of subcutaneous furosemide infusions in the community as a means of palliating episodes of fluid overload in patient homes.


Over 3 years, 101 patients have been referred to our service; 60 patients are now deceased (mean time in service: 225days), and 41 are still receiving on-going care (mean time in service: 303 days). 12 hospital bed days for each deceased patient and 15.5 bed days for each on-going patient have been avoided. Death at home (preferred place of death) has increased from 18% to 58%. 90% of patients would recommended the service to others and have that the care they received was compassionate and coordinated. 80% reported that symptom control was improved and that integration of care with the cardiology heart failure team was beneficial.


This model is highly sustainable as the cost-savings approximate to £10K per patient referral. Key elements of the pathway include the strong co-speciality relationships, cross boundary approach, multi-disciplinary team working, and use of electronic communication and virtual clinics. We feel that our model has the potential to transpose and adapt to other chronic advanced conditions such as end stage renal, respiratory and liver disease.

How to Cite: Atkinson C. Development of a transitional cross-boundary supportive care service for advanced heart failure patients. International Journal of Integrated Care. 2021;21(S1):34. DOI:
Published on 01 Sep 2021.


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