Local models
Based on the core components, local models were developed in north-east Glasgow, Inverclyde and south-west Glasgow to improve palliative care for people with heart failure.
These local models were designed by facilitation groups made up of hospital, hospice and community professionals. Together, they tailored the core components to meet local needs and demand for existing services and make the best use of existing resources.
North-east Glasgow: an urban area with a population of 224,000
- Weekly outpatient clinic staffed by a consultant cardiologist with special interest in palliative care and heart failure, as well as a heart failure nurse trained in palliative care.
- Patients seen for cardiological assessment, optimisation of therapy (to ensure they are on the best medication for their condition and that there is no further appropriate surgery or treatment to improve their symptoms), assessment of palliative care needs and generalist palliative care interventions and support.
- Where appropriate, a medical anticipatory care plan (MACP) is produced by the cardiologist.
- Holistic assessment undertaken by the nurse using the Caring Together holistic assessment tool.
- The outcome of the outpatient consultation is communicated to the patient's GP, district nurse and other healthcare professionals, either via circulation of the MACP or standard format letter.
Inverclyde: a mainly rural area with a population of 81,000
- Monthly clinic staffed by a consultant cardiologist and a heart failure specialist nurse.
- Patients seen for cardiological assessment, optimisation of therapy where appropriate and advice on palliative care interventions and support.
- A care manager, usually the clinic nurse or another heart failure nurse, is allocated to co-ordinate the care of the patient.
- The outcome of the outpatient consultation is communicated to the patient's GP, district nurse and other healthcare professionals.
South-west Glasgow: a mainly urban area with a population of 117,000 people
- Weekly clinic staffed by a consultant cardiologist and a heart failure specialist nurse (HFSN).
- Patients seen for cardiological assessment and optimisation of therapy.
- The HFSN undertakes the holistic assessment and gives advice on palliative care interventions and support.
- A care manager, usually the clinic nurse or another heart failure nurse, is allocated to co-ordinate the care of the patient.
- The outcome of the outpatient consultation is communicated to the patient's GP, district nurse and other healthcare professionals.