The guidelines Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes [NG5] 2015 and Multimorbidity: clinical assessment and management [NG56] 2016 were also identified as covering similar findings on the management of transition and continuity of patient care. Continuity: It was found that heart failure care that is spread across different healthcare settings is fragmented, and this can have a negative effect on peoples confidence in their management plans. The evidence showed that primary healthcare services, and especially general practitioners, were good at providing continuity of care and individualised, holistic care. It suggested that specialist services should, attempt to integrate into existing primary care structures. Evidence showed that discharge from HF specialist services to general practice can be seen as a loss by patients. The reasons for this were thought to be multifactorial and concerned the difference between specialist and GP care. These included a real or perceived reduction in the focus on the condition, a reduced awareness of the intricacies of the condition, and unfamiliarity with the history of the condition and its exacerbations. In addition to this there may be an increase in the person with HF s sense of vulnerability at being away from specialist care or his/her access to specialist care. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Co-ordination: The evidence suggested that patients find the healthcare system poorly co-ordinated and confusing to navigate. This leads to increased treatment burden, and sometimes even conflicting advice. Models to improve co-ordination suggested by health care professionals (HCPs) in the studies included a single care-coordinator, a shared-care protocol between primary and secondary care, and using HF nurses as a bridge between primary and secondary care. 