Expert Voice: Evaluation of a Joint Palliative Care and Heart Failure Clinic in the Hospice Setting

By Roberts A 1,2 , Waiganjo K 1 , Coleman E 2 , Wood M 2.

1 Moya Cole Hospice, Little Hulton, Manchester, M28 0FE, Manchester Greater Manchester, United Kingdom.

2 Northern care Alliance, Salford Greater Manchester, United Kingdom.

Background 

In the three years to March 2022, referrals to the Community Specialist Palliative Care Team (CSPCT) for patients with heart failure doubled in number. However, it was considered likely that there remained a significant unmet need, with patients frequently referred to the service at a very late stage. There was concern that this may mean that patients did not access specialist palliative care in a timely fashion, if at all. The CSPCT and Heart Failure Teams work very separately and identified that both services would benefit from development to enhance their skills for the benefit of patients with heart failure in the Salford community. 

Aims 

A service improvement initiative was agreed with the aim to improve the care and management of patients with heart failure, particularly in the last year of life, through improved collaboration between services, facilitating earlier access to specialist palliative care, timely advance care planning, hospital admission avoidance and improved knowledge and skills across both teams. 

Methods 

The key intervention was to establish a monthly joint palliative care and heart failure clinic for an initial one year pilot. The clinic is based at the hospice and replaces one of the Heart Failure Clinical Nurse Specialist’s (CNS) community clinics. A clinic was chosen in preference to community joint visits due to capacity in the Heart Failure Team (they are unable to offer home visits) and to introduce patients to the hospice environment. The clinic is led by a Heart Failure CNS with support from either a Palliative Medicine Consultant or an 8a Palliative Care CNS. The pilot was extended to two years due to low clinic numbers in the first year.  Additional interventions included CSPCT attendance at the monthly Heart Failure multidisciplinary team meeting (MDT) and education sessions for both CSPCT and Heart Failure Teams. Activity measures were collected at baseline and data was reviewed for the two year period from 1st January 2023 to 31st December 2024. IPOS questionnaires were introduced in clinic. Staff confidence was evaluated across both services using baseline and post-project surveys. 

Results 

A total of twenty-nine patients were referred with the majority of referrals from cardiology (24/29). Twenty-five patients accessed the clinic with an average of 1.6 (0-5) attendances per patient. The average age of patients referred was 79 years and 62% were male. Twenty-five had a recorded advance care planning discussion and eighteen had an EPaCCS entry completed (EPaCCS not introduced in Salford until June 2023). Eighteen patients accessed at least 1 (0-3) hospice service but none accessed the hospice IPU. Seven hospital admissions were recorded after the first clinic attendance. Data on admissions prior to introduction of the clinic is not available. Thirteen patients expressed a preference to die at home with only one wishing to die in hospital and three choosing hospice as their PPD. Of fourteen deaths, six were in hospital, five at home or in a care home and none were in a hospice. From the data available, 71% of patients who expressed a preference achieved their PPD. 57% of patients who did not express a preference died in hospital. Actual place of death was unavailable for 3/14 patients. 

Whilst the IPOS was used regularly in clinic to inform assessments, due to organisational factors we have been unable to analyse data to demonstrate patient reported outcomes.
Staff confidence showed little change between pre and post-project surveys. 

Overall, referrals to specialist palliative care services at the hospice actually reduced following the introduction of the joint clinic with a total of 65 patients referred in 2022-2023 and 54 patients in 2024-2025.  

Conclusion 

The joint palliative care and heart failure clinic is considered a positive development by the services involved, with improved collaboration between teams and a clear commitment to continue the clinic. Anecdotally patient selection has improved. Although numbers remain relatively low, attendance has improved since the clinic was first introduced. The majority of patients who were referred to the joint clinic accessed at least one hospice service. It is encouraging that most patients had documented evidence of an advance care planning discussion, although preferences regarding PPD were still unknown in a significant number of patients. Those who had not expressed a PPD mostly died in hospital, suggesting that there is still scope to improve advance care planning for this group of patients. 

This project has not resulted in the increase in referrals to wider hospice services that we expected. We can only speculate that this may reflect better patient selection or improved confidence of the heart failure team to manage patients without our direct support. We have encountered organisational challenges in collecting and analysing data which has made it more difficult to draw conclusions about the benefits of the clinic for the patients who have attended and any wider impact of the joint working. Further work is required to understand the benefits of our interventions so far and to establish whether or not the joint clinic and Heart failure MDT are the best approach.  

Recommendations:  

• Further education and exposure of different members of both teams to the clinic and MDT joint-working 

• Specialist palliative care attendance at cardiology clinics to further develop links and shared learning 

• Raising awareness of the clinic amongst other specialties and in primary care 

• Further work to improve advance care planning in this group of patients 

• Analysis of IPOS data to evaluate the impact of interventions 

• Consideration of a patient survey to evaluate their experience of the service to inform future developments