Identify & share Models of Care

This remit aims to identify, share and develop models of care, to support urban, remote and rural; primary, secondary and tertiary care heart failure services in Scotland, by creating a menu of ‘best practice’ that can be shared with all heart failure teams and in doing so will improve the care of patients in Scotland who have heart failure, through efficient and successful pathways.
In 2014/15, the remit team requested information on all heart failure pathways/models of care in existence throughout Scotland. The survey response rate was 100% – Thank you!
Examples of each pathway, collectively applicable to urban, remote and rural populations where possible, were collated. A menu of ‘Best Practice’ was then created and divided into 4 key themes:-

    • Diagnostic Pathways
    • Secondary Care Management
    • Interface with Specialities : Cardiac Rehabilitation, Palliative Care, Pharmacists, Psychology etc.
    • Reducing Readmission and Length of Stay

The vision for this remit is to continue to maintain up-to-date pathways information thus providing access to a national range of tools that can be locally adapted to avoid duplication of effort. If you have any questions, suggestions, or novel pathways that could be included in the future, please contact: Dr Clare Murphy Clare.Murphy@ggc.scot.nhs.uk

Resources

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Diagnostic Pathways

Secondary Care Management

Heart Failure Bundles

NHS Ayrshire and Arran Heart Failure Bundle

NHS Greater Glasgow and Clyde Heart Failure Bundle Checklist

NHS Lothian Heart Failure Bundle

Heart Failure Case Notes Review

NHS Tayside Heart Failure Casenotes Review

Heart Failure Clinic Letter

NHS Forth Valley Heart Failure Clinic Letter in SBAR Format

Heart Failure Immediate Discharge Letter

Heart Failure IDL template

NHS Lothian Heart failure IDL

Heart Failure Management Guidelines – Flow Charts

NHS Dumfries and Galloway Heart Failure Ambulatory Care

NHS Fife Primary care Flow Chart

NHS Grampian Heart Failure Guidelines

NHS Grampian Heart Failure Summary Guidelines

Referral pathway for CRT and ICD

CRT-ICD pathway

HF Hub CRT troubleshooting guide

ICD management and deactivation

NHS Dumfries and Galloway ICD Deactivation Policy

NHS Highland Guidance on Acute Management of ICD’s in the community setting

NHS Highland ICD deactivation policy

NHS Highland Operational policy on Deactivating ICD’s at End of Life

NHS Tayside ICD Deactivation guidlelines

NHS Lothian ICD deactivation policy April 2014

Scottish National Advanced Heart Failure Service

Information about the Scottish National Advanced Heart Failure Service:

  • who to refer
  • contra-indications to cardiac transplant
  • MCS referrals for cardiogenic shock

2020 SNAHFS Referral

Details for routine and urgent referral to SNAHFS can be found here

Interface with Specialties

Cardiac Rehabilitation

NHS Ayrshire and Arran cardiac rehab referral heartfailure

NHS Greater Glasgow and Clyde Referral form for Cardiac Rehab

NHS Tayside Heart Failure CR Physio Referral Form

End of Life Care

Final MACP Template with Summary

HF Supportive palliative care flow diagram

NHS Lothian HF Palliative Care

NHS Tayside ACP Example

NHS Tayside Palliative Services Referral Form

NHS Greater Glasgow and Clyde Hospice Referral form

Pharmacists

NHS Greater Glasgow and Clyde Post-MI LVSD Teach and Treat Programme

Improving medication optimisation in left ventricular systolic dysfunction after acute myocardial infarction

Psychology

NHS Greater Glasgow and Clyde Psychology Referral Process

NHS Greater Glasgow and Clyde Psychology staff info on service

Cardiac Obstetrics

Scottish Obstetric Cardiology Network – pathways of care and guidance relating to cardiac disease in pregnancy

Reducing Readmission and Length of Stay

National guidance for Heart Failure Care