Context & Challenge

Heart failure diagnoses are placing substantial pressures on the NHS and afflicting large swathes of the UK’s ageing population. With over 920,000 people living with heart failure nationally and a further 200,000 additional diagnoses made every year, the disease inordinately consumes clinical capacity, accounting for:

• 1 million bed days per year
• 2% of the NHS total budget (est. £2 billion*)
• 5% of all emergency hospital admissions

In particular, heart failure remains a disproportionately pervasive source of chronic illness within the East and North Hertfordshire Catchment. A comparative analysis conducted by RightCare between ENHT and its nine most demographically similar peers revealed 5-10 percent higher readmission rates and 15% higher non-elective spend within the region. Nonetheless, underdiagnosis alarmingly remains a persistent issue.

The Quality and Outcomes Framework indicates that the prevalence of diagnosed heart failure stands at only 0.7%, which is substantially lower than the estimated actual prevalence of 1.36%. This gap suggests that there is insufficient early detection and diagnosis, leading to greater pressures on hospitals in future from emergency admissions.

Failure to effectively augment community resilience in response to increasing patient numbers will only exacerbate existing problems, including:

• High Rates of Hospital Admission: Heart failure is the leading cause of hospital admissions in individuals over 65, with 70% of the annual cost of Heart Failure being related to hospitalisation.
  
  
• Underdiagnosis and Late Detection: 80% of patients are diagnosed with Heart Failure at the point of admission, despite 40% exhibiting pre-existing symptoms.
  
  
• Strained Clinical Capacity: During the 2021/2022 period, heart failure emergency admissions at ENHT accounted for 3,540 bed days. This translates to an average usage of 205 days per month or 10 beds per day. Notably, 30% of these beds were occupied by patients readmitted for heart failure. Additionally, ENHT nurse specialists managed 345 patients across designated heart failure clinics, with each patient receiving an average of 2.5 consultations over the year. This resulted in 886 clinic visits totalling 454 clinical hours. The data clearly show that delayed interventions not only consume significant clinical time but also place intense pressure on the already scarce bed availability.
  
  
• Health Inequalities: People with heart failure who live in areas of socio-economic deprivation and from mixed ethnic groups have higher rates of emergency admission due to poor access to streamlined medical support, including those in Lower Lea Valley and Stevenage. 

The Solution

Recognising the urgency to accelerate early detection efforts and address health inequalities, East and North Hertfordshire NHS Trust (ENHT) alongside Hertfordshire Community NHS Trust (HCT) have partnered with Doccla to pilot MHF@Home (Managing Heart Failure at Home) and innovate care models for heart failure patients. The pilot sought to test and develop a new model of care that would support heart failure patients in managing their condition at home through remote monitoring, guided self-management, and patient education to:

• Minimise unnecessary face-to-face (F2F) appointments and emergency admissions by detecting early signs of deterioration through remote monitoring
  
• Mobilise digital solutions to provide more streamlined and timely support for HF patients via multi-disciplinary teams, thus supporting earlier diagnosis.
  
• Promote patient-driven self-management via personalised care plans, reducing pressures on clinical capacity
  
• Address health inequalities by widening access to remote care among socioeconomically deprived communities

We completed the six month pilot programme in February 2024, after successfully onboarding 52 heart failure patients for remote monitoring. 66% of these patients were from Stevenage, demonstrating Doccla’s commitment to widening healthcare access to the most deprived communities.

The Results

Our pilot programme has yielded substantial benefits, driving tangible cost-savings. A Wilcoxon signed-rank test, which provides comparative assessments of system efficiencies three months prior and post launch, revealed the following results:

• 100% 30-day readmissions reduction
• 32% reduction in A&E visits for heart failure-related issues after joining the remote monitoring programme
• £558,601 of projected savings over a period of 6 months if applied to all heart failure patients at ENHT
• 86% of patients rated the service as good or very good
  

We have also improved clinical workflows by leveraging full multi-disciplinary team expertise across primary, community, and secondary care. Rather than working in silos, our pilot has fostered clear and efficient communication streams between GPs, heart failure teams, hospital cardiology, and other specialists, facilitating prompt referrals to specialists when needed.

In addition, patients reported substantial benefits from the program, including:

Improved Overall Health: Across the six months of MHF@H, patients reported an average increase in health from 65 to 72 out of 100. This improvement underscores the effectiveness of the MHF@Home initiative in fostering healthier lifestyles and better health management among its participants.

Improved Quality of Life: Patients were assessed against the EQ-5D-5L framework, a comprehensive assessment tool evaluating five crucial dimensions for quality of life. Our patients demonstrated measurable improves across all five metrics over the six month period, including:

• Mobility: Average mobility scores rose from 4.1 to 4.4 out of 5.
• Self-Care: 4.3 to 4.7
• Ability to Complete Usual Activities:  4.3 to 4.4
• Improvement in Pain/Discomfort: 3.9 to 4.5
• Improvement in Anxiety/Depression: 4.3 to 4.5

Reduced Limitations Caused by Heart Failures: On average following the six month pilot, patients reported a significant reduction in the impediments imposed by heart failure on their ability to:

• Pursue hobbies and recreational activities: Average reduction from 2.6 to 2.4 out of 3
• Visit friends or family: Average reduction from 2.1 to 1.7
• Sustain intimate or sexual relationships: Average reduction from 1.6 to 1.5

Most notably, the pilot programme has been a pivotal impetus for empowering patients in becoming active agents of their own health. The pilot launched a comprehensive personalised care approach, where patients worked with clinicians to develop care plans best suited to their lifestyles and intended health outcomes, increasing choice and flexibility in type of care received. We also provided patients with self-management tools, including health-coaching, self-management education, home-based options such as REACH-HF, peer support and Patient Initiated Follow Up (PIFU).

The impact of this pilot has also been by the healthcare community, receiving the ‘Most Promising Pilot in 2024’ award at the HTN Awards.

These results will be compiled into an interim report to shape a theory of change framework, offering critical insights to guide future improvements and support strategic expansion across the UK

Conclusion

The Managing Heart Failure at Home (MHF@H) pilot at ENHT and HCT has not only demonstrated the potential for large-scale, impactful adoption but has also laid the foundation for a sustainable, patient-centred model of care that can be adapted across diverse healthcare settings. The pilot’s design has been structured to optimise three critical areas for success: scalability, sustainability, and spread.

Scalability

Drawing on our accumulated experience at ENHT, Doccla has developed a service blueprint that integrates best practices to enhance patient outcomes and streamline heart failure management. This blueprint is currently being tested in an extended rollout within Lower Lea Valley, focusing on three key initiatives:

1. Patient-centric care that ensures care is tailored to individual needs.

2. A collaborative, multidisciplinary approach that leverages the expertise of diverse teams.

3. Data-driven decisions that refine our service and ensure timely, responsive care.

By embedding CQC-registered, in-reach remote monitoring nurses, Doccla addresses the challenge of utilisation, a key barrier to scaling. Our nurses now actively identify and onboard suitable candidates for monitoring, conduct initial patient assessments, support clinician engagement with the service, and provide training to build clinicians’ capacity to use the system effectively. These strategies allow us to increase the number of concurrent patients while supporting ongoing growth of the programme’s reach.

Sustainability

At the core of the MHF@H model is patient self-management, a central tenet that enables long-term sustainability by empowering patients to take active roles in their health. The programme provides every patient with an information pack containing essential resources, such as the Pocket Guide to Heart Failure and My Appointment Diary, designed collaboratively by patients and heart failure specialists to meet the unique needs of the cohort.

Patients are further supported by educational tools, including the Pumping Marvellous Foundation Traffic Light Symptom Checker, which offers patients a clear, visual understanding of symptom severity. This resource not only enables self-assessment but also offers concrete actions at each level, fostering proactive care and bridging communication between patients and their care providers.

To address staffing limitations, Doccla has invested in upskilling clinical staff with relevant courses, ensuring that the programme maintains high standards of care despite a shortage of skilled clinical workers. By integrating community-based resources with clinical expertise, Doccla fosters resilience within the healthcare system, enabling sustained patient self-management and reducing strain on clinical staff and facilities.

Spread

To facilitate cross-site adoption of the MHF@H model, Doccla hosts regular networking sessions for clinicians, encouraging co-learning and continuous improvement. In these sessions, healthcare professionals share implementation strategies, discuss challenges and successes, and explore digital tools to enhance remote monitoring. Topics also include enablers and barriers to adopting MHF@Home approaches, mapping patient pathways, and addressing health inequalities and comorbidities.

By cultivating a spirit of knowledge-sharing and collaboration, these sessions ensure that lessons learned are disseminated across sites, enabling the spread of best practices and fostering consistency in patient care standards.

The Path Forward

With its scalable, sustainable, and collaborative design, the MHF@H pilot at ENHT exemplifies a replicable model that transforms heart failure care. The programme’s proactive approach to remote monitoring, patient education, and clinician support underscores a significant shift toward a more resilient healthcare system. As MHF@H continues to expand, it holds the promise of transforming heart failure management nationwide, achieving measurable clinical and economic benefits for healthcare providers and patients alike.

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