What should the primary care team do for people with heart failure?
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 specialist heart failure 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 summary and 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; and arrange access to specialist heart failure services if needed.