[2018] Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 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 o a named healthcare coordinator (usually a specialist heart failure nurse) o local heart failure specialist care providers, for urgent care or review. additional sources of information for people with heart failure. 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] Findings identified in the evidence synthesis The review findings were grouped into findings and subfindings following the structure of the recommendations on continuity of care from the NICE Guideline CG138 Patient experience in adult NHS services in which four aspects of continuity of care were identified: continuity, co-ordination, communication and contact/access to health professionals and services. In addition the role of specialist services was identified as an important aspect of continuity of care for people with heart failure. For each of the five subfindings of continuity, the review identified challenges, as well as suggestions for improvement, and examples of how transition in heart failure care in particular could affect patients and patient care. 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. 