Understanding heart failure service innovations in Lincolnshire: a realist qualitative study.

Problem

Increasing prevalence of heart failure creates healthcare demand and presents challenges to fragmented health systems. In response to these challenges, an innovative heart failure intervention was implemented in Lincolnshire. The intervention included integrated community cardiology, remote monitoring using a digital application, virtual ward, and same-day emergency care (SDEC) for intravenous (IV) diuretics. Services were expanded to seven-days a week. A multidisciplinary team (MDT) included health professionals from secondary care, primary care, the community heart failure team, and commissioners. The implementation and success of healthcare interventions depend on the contexts and mechanisms in which they are implemented. This study aimed to explore the contexts and mechanisms of these new heart failure services, focusing on identifying what worked for whom, how, and in what circumstances.

Approach

Using realist framework principles, we developed an initial programme theory and conducted 15 qualitative in-depth interviews with a cardiology consultant, nine primary care staff (General practitioners, Nurses, and Pharmacists), one service manager, and four patients. Thematic analysis facilitated the understanding of contexts and mechanisms leading to observed outcomes (CMO). The findings contributed to the refinement of CMO configurations, revealing the contexts and mechanisms that explained why and how heart failure services worked and in these circumstances.

Findings

CMO configurations were used to explain why and how heart failure services worked for patients. The context of expanded and up-skilled community nursing was an important facilitator of new heart failure services. Community nurses played an important role in remote monitoring, home visits, formulation of personalised care, and patient-centred care delivery. The integration of remote monitoring, virtual wards, and home visits ensured the continual provision of care beyond health facilities, and expanded access to care. The referral mechanism from community nurses to SDEC was effective in delivering IV diuretic services. However, remote monitoring was lacking for SDEC-discharged patients. Collaboration with a third-sector organisation further facilitated care provision for immobile patients and those needing emergency care. The expansion to a seven-day a week service improved access to care. Interprofessional collaboration was a key mechanism influencing MDT functioning in identifying clinical and operational strategies for complex patient management. The community heart failure intervention improved care provision and patient experience by delivering specialised care closer to patients' homes and promoting patient recovery. The key CMO structure involved interprofessional collaboration, expansion and upskilling of nurses, digital applications, remote monitoring, and referral mechanisms.

Consequences

The study identified key contextual factors and mechanisms contributing to the effectiveness of new heart failure services for patients, and highlighted challenges that require ongoing attention. Given the increasing demand for heart failure care and national interest in virtual service delivery, this study provides evidence for recognising and strategising future heart failure services in similar contexts.