Integrated Heart Failure Service
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The Integrated Heart Failure Service (IHFS) improves outcomes for people living with heart failure across East and North Hertfordshire (ENH) by providing coordinated, specialist care closer to home. The service supports early identification, diagnosis and proactive management; while helping patients access the services they need to manage their condition with confidence.
Led by specialist heart failure nurses, with clinical support from consultant cardiologists, we provide personalised, holistic care tailored to each patient's needs. Care is delivered primarily in patients' homes, with specialist nurses working closely with community nurses, primary care teams, hospices and other healthcare professionals to assess, treat, support and educate patients living with heart failure.
We deliver evidence-based care in line with national and international heart failure guidelines, ensuring treatment is tailored to each person’s clinical needs and circumstances. Our team empowers patients through education and self-management support, enabling them to better understand their condition, recognise symptoms and make informed decisions about their care, improving both health outcomes and quality of life.
We also provide specialist advice and clinical guidance to GPs and community healthcare professionals, supporting consistent, high-quality heart failure management across the local health system. We have strong links with palliative care services and local hospices to ensure patients with advanced heart failure have timely access to symptom management, supportive and rehabilitative services, and coordinated end-of-life care, when appropriate.
By bringing together primary, community, acute, mental health and palliative care services, we provide seamless, coordinated care centred around the person. This integrated approach helps reduce hospital admissions, improves patients' experience of care, and enables more people to live well with heart failure for longer.
- How the Service is provided
- Making a referral
- Patient experience
- Useful information
- What will happen at your appointment
- Who is eligible for the service
How the Service is provided
We provide care through a combination of outpatient clinics, home visits for patients who are unable to attend clinic, and telephone consultations, depending on your individual needs and clinical condition.
Our specialist heart failure nurses will assess, monitor and support you to ensure your heart failure is managed in line with the latest evidence-based guidance. We will review your symptoms, optimise your medication where appropriate, monitor your condition and provide education to help you understand and confidently self-manage your heart failure. With your consent, we can also refer you to other health and community services that may benefit you, and we are happy to provide information and support to your family and carers.
Our aim is to help you manage your condition, maintain your independence and improve your quality of life, while reducing the risk of your symptoms worsening or requiring hospital admission.
The frequency and type of your appointments will depend on your clinical needs. As your condition stabilises, you may be discharged back to the care of your GP or usual healthcare team. If your condition changes in the future, you or your healthcare professional can refer you back to the service if further specialist heart failure support is required
Making a referral
All new patients must be referred to the service by a healthcare professional. We do not accept self-referrals for new patients.
If you have previously been under the care of the Integrated Heart Failure Service and your symptoms have changed or worsened, please contact the service on 01438 583239. A member of the clinical team will review your enquiry and advise on the most appropriate next steps.
Information for Healthcare Professionals
Healthcare professionals can refer patients to the Integrated Heart Failure Service by completing:
- our referral form
- an electronic referral via SystmOne.
- a referral form sent to the service email address.
Please include a completed referral form together with relevant clinical information, such as a patient summary, recent investigations and / or a hospital discharge letter, to support triage and ensure timely assessment.
If you have any questions about the referral process, please contact the service on 01438 583239.
Patient experience
We would appreciate feedback on your recent experience of our service by completing our short survey.
If you have limited access to technology and would prefer to have a Feedback Form, please ask our clinical team for a copy when you attend your assessment.
Useful information
British Heart Foundation (BHF)
Information about heart failure, treatments, medicines, healthy living, emotional support and patient resources.
The UK's patient-led heart failure charity, providing education, symptom diaries, medication information, self-management tools and peer support.
Trusted NHS information on heart failure symptoms, diagnosis, treatment, living with heart failure and available support services.
What will happen at your appointment
When we receive your referral, it will be reviewed by the heart failure team and prioritised according to clinical need. Once accepted, you will be added to our waiting list. When an appointment becomes available, one of our administrators will contact you by telephone to arrange a convenient date and time.
Appointments are usually arranged 1 to 2 weeks in advance, so expect a telephone call offering available appointment times.
Most appointments take place in a heart failure clinic. If you are unable to attend because you are housebound, we can arrange a home visit. Some follow-up appointments may be carried out by telephone, depending on your clinical needs and preferences. The appointment type, time and location will be confirmed when we contact you.
You are welcome to bring a family member, friend or carer with you to your appointment.
Your first appointment is usually longer than follow-up appointments; please allow up to 90 minutes.
After a comprehensive assessment, we will agree a personalised plan of care and treatment tailored to your heart failure symptoms, medical needs and personal circumstances.
Who is eligible for the service
Acceptance criteria:
- Patients over the age of 18 with a GP in East and North Hertfordshire
- Any patients with a heart failure diagnosis (confirmed diagnosis on ECHO/MRI)
- HFrEF – EF ≤40%
- HFpEF –EF ≥40% with evidence of diastolic dysfunction or RV dysfunction or severe valvular disease for medical management.
Exclusion Criteria:
- ECHO or MRI not available confirming a heart failure diagnosis
- End stage renal disease CKD V eGFR≤ 15/ patients on dialysis
- CKD IV eGFR ≤30 without a management plan from cardiologist / renal consultant
- Patients awaiting AVR / MVR
- Patients echoed in atrial arrhythmias with HR exceeding 100 bpm require rate control and re-echo before referral
- Immeadiately post MI — must have had post MI echo at 6 weeks
- HFpEF patients that are not on a medium dose loop diuretic (80mg furosemide or bumetanide equivalent) and with no recent HF admission.
