Project Name: Further Development of Integrated Heart Failure (“HF”) Service

Project Summary:

The CWP aims to enhance the existing Community Heart Failure Service provided by the CW Partner in Ealing Borough, which is an area covered by the CW Partner’s care, by recruiting an additional Heart Failure Specialist Nurse to implement virtual wards for heart failure patients. Heart failure virtual wards provide an excellent opportunity to monitor patients in the community with specialist support using digital technology to support patients remotely, for those that would benefit from specialist intervention.

Virtual Wards, also known as “hospital at home”, allows patients to be remotely monitored at home safely rather than them remaining in hospital as an inpatient. The virtual ward will also aid access to those who find it more difficult to access healthcare   and support services and help to reduce health inequalities and equity.

Planned Milestones:

  • CWP kick-off meeting.
  • Baseline data collated to measure project outcomes against.
  • Recruit and on-board Heart Failure Specialist Nurse
  • Develop and implement virtual wards, including necessary technology infrastructure and protocols.
  • Project progress check in meetings, including latest clinical activity data.
  • Analysis of CWP data, submission of final CWP report, submission of outcomes summary.
  • CWP wrap up meeting.

Expected Benefits:

For the Patient:

  • Enhanced access to specialised care and support from a dedicated Heart Failure Specialist Nurse (HFSN) and multi-disciplinary team (MDT).
  • Improved self-management skills, leading to a more efficient control of heart failure symptoms and reduced hospital admissions.
  • Increased convenience and reduced travel for patients through the implementation of virtual wards.
  • Early intervention and reduction in hospital admissions.
  • Improved access to diagnosis and optimised treatment.
  • Constant care and access to care.
  • Enhanced experience for patients and their carers.

For the CW Partner:

  • Decreased burden on hospital resources by reducing heart failure-related admissions and emergency department visits.
  • Improved patient outcomes, resulting in potential cost savings.
  • Better quality of life and access to the heart failure service.
  • Increase proportion of patients identified with HF being managed in accordance with NICE guideline standards.
  • Enabling, through reviewing intervention, ongoing redesign of the service and workforce provision.

For Novartis: 

  • Further opportunities for the appropriate use of cardiology licensed medicines in line with NICE guidelines, including Novartis’s medicine.
  • Enhanced reputation.
  • Ethical, professional, and transparent relationship and trust between Novartis and the NHS.
  • Strengthened reputation as a provider of high-quality heart failure care.

Start Date & Duration: September 2023 for 20 months

UK2309088391

Project Name: Collaborative Working Project (“CWP”) Further Development of Integrated Heart Failure (“HF”) Service.

Organisation(s): Imperial College Healthcare NHS Trust, The Bays, South Wharf Road, London W2 1NY (the “CW Partner”) 

Completion Date: 8th April 2025

Outcome Summary: 

The CWP saw an estimated 1,400 referrals to emergency day-unit ambulatory care (EDAC) in one year, highlighting a significant positive service impact in the avoidance of 1,400 hospital admissions during the CWP. An average of 35-45 referrals per week was achieved versus the national average of 20 per month, and 318 patients were moved into inactive caseload due to optimisation and successful management.

Key Project Outcomes Data: 

The CWP:

  • Moved 318 patients into inactive caseload due to optimisation and successful management.
  • Monitored a total of 364 patients: Virtual Ward: 107 / Remote Monitoring: 257
  • Made an estimated 1,400 referrals to emergency day-unit ambulatory care (EDAC) in one year, highlighting a significant positive service impact in the avoidance of 1,400 hospital admissions during the CWP. An average of 35-45 referrals per week was achieved versus the national average of 20 per month. Since completion of the project, referrals have increased to 40-50 per week.
  • The rise in admissions <3 days and subsequent decrease in measures >3 days indicate the success of the Virtual Ward.
  • Patient satisfaction scores related to the Community Heart Failure Service. (PREMS). Circa 90% satisfaction overall.
  • Patients rated the service as: 56% (40%) Very Good, 36% (10%) Good, 0% (50%) Neutral, 4% (0%) as Poor, 4% (0%) Don’t Know. A deep dive into negative feedback found that it mostly stemmed from technical barriers. Baseline figures are shown in brackets.
  • 6,508 patients were prescribed the four pillars’ medications during the course of this CWP.

Outcomes: 

  • Baseline data collated to measure project outcomes against.
  • Recruited and on-boarded Heart Failure Specialist Nurse.
  • The project developed and implemented remote monitoring, including necessary technology infrastructure and protocols to avoid hospitalisation for 1,400 patients.

Quote from Partner: 

“The project provided a significant boost to our already busy heart failure service. At a time when it is difficult to secure extra posts within the NHS we were grateful for the support provided. It facilitated optimisation remotely of disease modifying medications for patients who found getting to appointments difficult i.e., housebound, work or carer commitments ensuring equitable access for all, regardless of age, language spoken or IT literacy.”

Conclusion: 

The conclusion of the project highlighted the sheer volume of patients seen in the service, the success following optimisation of disease modifying medications in a timely fashion, improvement of debilitating symptoms and prevention of hospitalisation due to decompensation of patient heart failure. Remote monitoring can be successfully utilised to optimise disease modifying medications. Its success, however, is dependent on efficient experienced support from heart failure nurses. Nonetheless, patients should be carefully screened and advised on the role of remote monitoring prior to enrolment to ensure adherence and reduce risk of drop-outs. If patients have a history of poor adherence to medications this will not change with remote monitoring. 

Old age does not necessarily exclude patients, and many were optimised on remote monitoring with the support of family and IT upskilling.

Service restrictions (no electronic prescribing) inhibited the efficiency of optimisation as GP responses to requests for medication changes were slow.

FA-11551602 | November 2025