Last week Dr Sharma explained why Oldham CCG was thinking differently about vascular care.
Oldham’s plans include clinicians, commissioners, community and local consultants working in collaboration; supporting general practice through education; focusing on outcomes rather than activity; improving CVD risk-assessment to improve vascular health and reduce health inequalities.
Plans include aiming to transfer 90% of patients suitable for discharge back in to the community; using active case management, personalised care planning and support to self care through telehealth — a system which helps people with HF to manage their conditions; rebuilding the previously poor relationship with secondary care colleagues and jointly producing disease diagnosis and management pathway.
There is also a focus on evidenced-based decision to treatment to be made by clinicians based on what is most clinically appropriate for that particular patient, our raison d’être for setting up a clinically-led team was not to save money but to improve the quality of patient’s care and experience; identifying the new ways of meeting the increasing demand for urgent care, to improve self care, end-of-life care and extend preventive care; and identifying duplication of work in primary and secondary care and addressing it.
Why HF? (additional material by Tim Drowley, lead service improvement partner,directorate of system reform and service innovation, NHS Oldham)
- It is a common final pathway of all cardiac diseases
- 40% of patients with HF die within a year
- 5% of all deaths in the UK are due to HF
- It accounts for 5% of all medical admissions
- 16% of patients with HF get readmitted
- HF referrals to outpatients currently cost the NHS more than £35m per year.
- In 2010/11, the emergency admission rate for HF in Oldham was (60.6 per 100,000). England’s is 59.8 per 100,000
- Providing a B-type natriuretic peptide (BNP) test can rule out HF with 98% accuracy at a cost of £25
- A simple diagnostic algorithm like NICE’s can reduce unnecessary cardiology referrals (New cardiology outpatient referral costs £215)
Oldham programme objectives
To develop a community heart failure service for Oldham, providing an effective early diagnosis and proactive management in primary care including BNP testing.
To optimise treatment and provide frequent monitoring in primary care after confirmation of diagnosis. This should include body weight, BP, pulse.
Check, renal functions and nutritional status.
To deliver care closer to patient’s home.
To reduce the number of referrals to cardiologist.
To prevent expensive emergency admissions and increase life expectancy.
To reduce the length of stay.
To provide rehabilitation to patients with stable heart failure.
To plan end-of-life care pathway to avoid unnecessary hospital admission.
To provide an information and educational resource for patients.
Integrate assessment and referral for device therapy into patient’s pathway.
- Provision of NT-proBNP test to GPs - rule out test for HF - start in Jan 2013
- In Oldham we decided to go for NT-proBNP because this is relatively stable in EDTA plasma for up to 48 hours at room temperature whereas measurable BNP levels drop significantly after only four hours and by half after 48 hours. When stored refrigerated at 4 C plasma BNP will also decrease significantly while NT-proBNP levels will remain stable for up to six days.
- Six-month HF pilot project – outcome-focused allowing existing providers to offer innovative solutions - will start in Jan 2013
- Pathway agreed following input from relevant health care professionals across primary and secondary care
- Education and support to primary care - two educational sessions have already been provided to Oldham GPs. This included diagnostic algorithm as in NICE guidance to quickly identify patients with heart failure, referral to rapid access heart failure clinic in the hospital and clinical case scenario discussion.
- Involvement with telehealth to enable patient self management. This will start in 2013.
Stroke and TIA (additional material by Darren Biega, service improvement partner, reform and innovation, NHS Oldham, and John McEwan head of commissioning at Oldham CCG)
The observed prevalence (GP registered) of stroke is 66.4% in Oldham as compared with 67.4% for England. The emergency admission rate for stroke is significantly higher than the national average. There are 450 strokes per year in Oldham. Stroke accounts for 19.83 years of premature deaths in men and 16.43 in women per 10,000 in those under the age of 75 years.
There are a slightly lower proportion of stroke patients under the age of 75 discharged to home or usual place of residence compared with the national average – Oldham (68.7%), England (77.3%). Oldham’s BME population is 17.1% (excluding white Irish and white others). Stroke prevalence and mortality is higher in BME.
- Primary care to become proactive as 80% of strokes can be prevented.
- To use GRASP-AF tool in identifying patients with AF at risk and provide appropriate intervention with anticoagulants. To encourage practices to download the free tool from PRIMIS Profile Centre.
- TIAs are an important determinant of stroke - education for primary care physicians involving the local stroke consultants.
- Early assessment, management and imaging in people with TIA, as per NICE.
- To encourage all practitioners to use CHADS2 clinical prediction tool to assess the risk of stroke in patients with AF.
- To raise awareness of stroke and TIA especially BME population
- NICE guidance to be adhered for rapid recognition of symptoms and diagnosis, emergency treatment for people with acute stroke and pharmacological treatment for people with acute stroke.
- To work with local stakeholders to understand and, where necessary, alter the local stroke service pathway
- To improve the current patient assessment systems – to identify those patients in the hyper-acute stage of stroke, enabling
- Access to the most appropriate pathway of care
- To develop a robust reporting tool/mechanism sharing with other providers (for example: the local authority, enablement team, discharge liaison, early supported discharge and stroke rehabilitation colleagues
- To develop Greater Manchester Stroke Rehabilitation Service aspiring to deliver inpatient provision of rehabilitation seven days a week, Early supported discharge six days a week and community stroke service rehabilitation five days a week
- To provide six month review as recommended by NICE.
- To do pulse checks as part of health checks.
- To reduce the length of stay in hospital
- To use the Greater Manchester Stroke Assessment Tool assessing the long-term needs of stroke patients and their carers, an evidenced-based tool to identify and address individual’s unmet post-stroke needs from across health, social and emotional care domains
Regular monthly meetings established with local consultants and other providers, for example the local authority and stroke rehabilitation team. The aim is to optimise agreed care pathways to avoid disability and mortality and to identify the areas where services need to be improved for acute care.
Two educational meetings have been held for primary care emphasising the modification of risk factors and improved medicine management. A TIA referral and treatment pathway is in place, TIA awareness and prevention focussing on south Asian population held in April 2012. A stroke awareness van provided some health checks on that day.
Practice support given to help practices with stroke assessment tool by CHD service coordinator NHS Oldham and regarding downloading and use of CHADS2 tool.
At the time of writing Greater Manchester Integrated Stroke Service (GMISS) has proposed a new operating model for centralisation. The vascular team remains engaged with the proposed model for centralisation of patient’s journey with suspected stroke.
DVT (additional material by Tim Drowley, lead service improvement partner, directorate of system reform and service innovation, NHS Oldham.)Venous thromboembolism (VTE) is an important cause of death and its prevention has recently been made a priority. In June 2012 NICE published new guidelines on the management of confirmed or suspected venous thromboembolic diseases in adults. The vascular team in Oldham identified this as a priority to improve identification and management of DVT and pulmonary embolism long before the published guidelines.
- Timely and accurate diagnosis of VTE which can result in death if left untreated.
- Diagnosis and management in the primary care setting.
- To reduce post-thrombotic syndrome as this can have a major effect on patient’s quality of life
- To establish diagnostic pathway based on NICE clinical guideline—NICE Clinical Guideline 144 on VTE
- To use two-level Wells scores in suspected VTE cases
- To prevent unnecessary hospital admission and imaging
- To identify the special risk group—IV, drug users, patients with cancer, nursing home patients
- Primary care education and referral guidelines.
- Communication channels opened. Regular meetings with secondary care consultants, DVT nurse practitioners and commissioners.
- Gaps in service provisions as per NICE guidelines have been identified
- The most clinically and cost effective pathway has been agreed by the clinicians—clinical diagnostic scores, D-dimer, ultrasound and radiological imaging.
- Agreement on who will be doing and actioning the anticoagulation monitoring (exceptions some GP practices who do in house anticoagulation monitoring).
- Improve the GP referral to secondary care - work ongoing
- Improve the discharge slip from the secondary care detailing the length of anticoagulation
- Firm up on interim parenteral anticoagulation therapy in patients where the appropriate diagnostic tests cannot be carried out (out of hours or weekends)
- GP education
- Look in to point of care D-dimer test to make it easier for primary care
- Thrombophilia testing. Which patients and who will do the test-primary/secondary care.
Dr Sharma is clinical director for vascular and medicine management at Oldham CCG, Greater Manchester.