Patients with heart failure managed by community heart failure specialist nurses (CHFSNs) may have episodes of (often unrelated) ill-health managed separately in hospital. Inadequate communication and multi-disciplinary working between these different providers can impact on the effectiveness of care.

This service improvement project explored the potential of patient-held alert cards to improve communication and continuity of care for heart failure patients moving between CHFSNs and hospital settings.

Alert cards were distributed to 119 patients on a community case load for presentation at hospital or emergency department. Follow-up data were obtained from practitioners and patients at 12 months.

At 12 months, 38 patients from the CHFSN caseload experienced 61 hospital admissions. CHFSNs were informed of 80% of admissions by practitioners (61%) and family members (38%). They were also informed of 59% of discharges. Notification of admission by hospital staff increased from zero in the previous 12 months, to 19 notifications. CHFSNs were more involved with hospital care, and patients reported increased confidence with the alert cards.

The study has shown that alert cards can increase the involvement of CHFSNs in the ongoing care and discharge planning process. They can also empower patients and carers to take an active role in their own care.