See also the economic article selection flow chart in Appendix D. 9.3.5 Evidence statements Qualitative See the narrative summaries of review findings in section 1.3.3.1. Economic No relevant economic evaluations were identified. 9.3.6 Recommendations and link to evidence Recommendations The primary care team should carry out the following for people with heart failure at all times, including periods when the person is also receiving specailist heart failure care from the MDT: ensure effective communication links between different care settings and clinical services involved in the person s care lead a full review of the person s heart failure care, which may form part of a long-term conditions review recall the person at least every 6 months and update the clinical record ensure that changes to the clinical record are understood and agreed by the person with heart failure and shared with the specialist heart failure MDT arrange access to specialist heart failure services if needed. [2018] Care after an acute event For recommendations on the diagnosis and management of acute heart failure see NICE s guideline on acute heart failure. The primary care team should take over routine management of heart failure as soon as it has been stabilised and its management optimised. Writing a care plan 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] Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. 