Connected Heart Care Pathway is available to some primary care networks (PCNs) in Camden and Haringey. It aims to achieve an end-to-end integrated pathway for managing heart failure, across primary and secondary care, as well as community services.
The overall ambition is to join up existing elements of the heart failure management pathways, expand and scale the pathways, and test the addition of case finding and remote monitoring step down and step up into virtual wards.
Testing an end-to-end patient experience with the ambition of offering an integrated service that ensures patients are managed by the right teams at the right time and offered holistic personalised care support plan.
Another ambition is to drive care closer to home ensuring more people remain well in the place they call home.
The pathway focuses on three patient groups:
- Priority Group A: patients living with risk factors and suspected heart failure will go through a process of screening and diagnosis to reduce the prevalence gap.
- Priority Group B: patients living with heart failure who need their annual review will be invited in for their usual check-and-test appointment (known as a megaclinic in Camden) with a particular focus on heart failure tests to ensure they are still managing their condition well.
- Priority Group C: patients living with heart failure who may be eligible for remote monitoring will be referred by secondary care into our integrated MDT, where eligibility for remote monitoring will be confirmed. At this point, the patient will be referred onto the remote monitoring platform Ortus iHealth where they will go through a process of rapid up-titration, supported by our dedicated clinical team and Digital Care Coordinator.
Care home patients, housebound patients and those without mobile numbers (priority group C only) are excluded.
The pathway is delivered in Haringey's NW PCN and SW PCN, and in North Camden PCN as a cross organisational collaboration between: Haringey GP Federation, NW PCN, SW PCN, North Camden PCN, Whittington Health and Royal Free London.
For more details, visit the Haringey GP Federation's dedicated website page or contact Marian Orafu.
Connected Heart Care Pathway
Haringey GP Federation website
https://www.haringeygpfedportal.co.uk