If stable patients are managed in general practice, they will need regular review, informed by their needs. The committee emphasised the importance of a personalised approach, such as that described in the NICE multi-morbidity guideline (https://www.nice.org.uk/guidance/ng56). Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 9.3 Transition between heart failure care settings Given the chronic nature of heart failure and its occurrence in populations in whom multiple morbidities are common, management of heart failure involves interaction between primary and secondary care services. People with heart failure are often admitted to secondary care settings with acute deterioration in heart failure (see NICE acute heart failure; CG187) and then transferred to the care of the heart failure multidisciplinary team (MDT) for management in the community. Once their clinical care has been optimised, people with heart failure are discharged back to the care of the routine primary care service but may need to re-access care thorugh the MDT. Evidence has accumulated that that the complicated nature of these transfer processes and the complexity of liaison between different teams can affect the quality of care delivered to people with heart failure. This question reviewed patient and staff experiences of these transfer processes and sought to find evidence on how these could be improved. 9.3.2 Review question: What are the experiences/preferences of staff and patients during transition between different heart failure care settings (including primary, secondary and community care)? For full details see review protocol in Appendix A. Table 130: Characteristics of review question Objective Explore patient and staff experiences and preferences regarding transition and continuity of care at the interface of different care settings in heart failure. 