Core components

 I – Patient identification and referral

• Have a diagnosis of advanced heart failure (NYHA III or IV).
• Have distressing or debilitating symptoms despite optimal medical therapy.
• Have supportive or palliative care needs that may include a combination of physical, social, emotional, spiritual or psychological needs. 

 II – Holistic assessment of patient

• Cardiology review: this could be outpatient/in-patient as appropriate.
• Holistic assessment: review with patient the physical, social, psychological and spiritual aspects of their needs to identify appropriate solutions. The Caring Together holistic assessment tool (HAT) provides prompts and supports the holistic assessment of both patients and carers.
• Caring Together has developed a medical anticipatory care plan (MACP). The care plan is completed by the patient’s cardiologist and includes concise information on the patient’s medical and palliative care needs, their understanding of their condition and prognosis, and their place of care and Do-Not-Attempt-Cardiopulmonary-Resuscitation preferences. The care plan is shared with the wider multidisciplinary team (and the patient if requested) to ensure that all are aware of the patient’s condition and preferences of care.

 III – Care management and co-ordination

• The patient is assigned a care manager (usually a heart failure nurse specialist), acting as the main point of contact for care management, information, advice and support.

 IV – Training and education

• Training and shared learning between specialities (palliative care/cardiology and service delivery settings, community/acute care).

 V – Multidisciplinary work and joint working

• Joint working and care co-ordination across teams (community, out-of-hours care and acute care).
• Care manager co-ordinates care with the multidisciplinary team and can action additional referrals if required.
• A care plan is devised with patients to fulfil personalised medical and palliative care needs.