The primary care team working within the specialist heart failure MDT should take over routine management of heart failure as soon as it has been stabilised and its management optimised. [2018] 9.5.2.2 Writing a care plan 77.The specialist heart failure MDT should write a summary for each person with heart failure that includes: diagnosis and aetiology medicines prescribed, monitoring of medicines, when medicines should be reviewed and any support the person needs to take the medicines functional abilities and any social care needs social circumstances, including carers' needs. [2018] 78.The summary should form the basis of a care plan for each person, which should include. plans for managing the person s heart failure, including follow-up care, rehabilitation and access to social care symptoms to look out for in case of deterioration a process for any subsequent access to the specialist heart failure MDT if needed contact details for: a named healthcare coordinator (usually a specialist heart failure nurse) local heart failure specialist care providers, for urgent care or review additional sources of information for people with heart failure. [2018] Chronic Heart Failure Domiciliary oxygen therapy in people with advanced heart failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 79.Give a copy of the care plan to the person with heart failure, ther family or carer if appropriate, and all health and social care professionals involved in their care. [2018] 9.5.3 Information and support needs regarding diagnosis and prognosis 80.When giving information to people with heart failure, follow the recommendations in the NICE guideline on patient experience in adult NHS services. [2018] 81.Discuss the person's prognosis in a sensitive, open and honest manner. Be frank about the uncertainty in predicting the course of their heart failure. Revisit this discussion as the person's condition evolves. 