Models of community heart failure care pathways. Dr Jim Moore GP & GPSI Cardiology Cheltenham,GLOS

Transcription

1 Models of community heart failure care pathways Dr Jim Moore GP & GPSI Cardiology Cheltenham,GLOS

2 Declaration of Conflict of Interests Dr Jim Moore GP and GPwSI in Cardiology, Cheltenham NICE Guideline Committee member -Chronic Heart Failure Chair of the GLOS CCG Circulatory Clinical Programme Group In the last year Honoraria received from Bayer for various activities including attending and participating in educational events and advisory boards

3 GHFS Guidelines

4 Plan u Background u Diagnosis u Management u Commissioning u GLOS HF service

5 Nice Chronic Heart Failure Pathway -essentials

6 Multidisciplinary team core professionals u HF specialist physician - cardiologist (with HF interest?) - physician with HF interest - GPSI u HF specialist nurse u Primary care - GP - Practice nurse - Pharmacy support u Others - pharmacist - cardiologist (electrophysiology) -Rehabilitation team - palliative care

7 Models of heart failure care pathways Aims The Model of Care aims to ensure people receive the right care, at the right time, by the right team and in the right place.

8 NICE Chronic Heart failure pathway

9 NICE Chronic Heart Failure Guideline 2010

10 Making a diagnosis in Primary care Advantages Knowledge of patient Background information Disadvantages Earlier stage of disease Triage nurse or GP Limited time Variable access to diagnostics NP Shared decision making Limited clinical experience

11 Prevalence 1.6% 1.4% Heart QOF Heart Failure Prevalence 2010/11 for NHS Gloucestershire u Variation in prevalence uqof average 0.7% u Predicted prevalence?1.1% 1.2% 1.0% Percentage 0.8% 0.6% 0.4% 0.2% 0.0% Y02384 L84609 Y02519 L84006 L84604 L84003 L84038 L84034 L84032 L84012 L84055 L84047 L84049 L84048 L84617 L84613 L84019 L84078 L84027 L84071 L84001 L84065 L84016 L84606 L84037 L84023 L84059 L84056 L84007 L84030 L84022 L84084 L84081 L84050 L84067 L84028 L84009 L84015 L84014 L84041 L84054 L84039 L84077 L84621 L84080 L84026 L84044 L84040 L84036 L84011 L84033 L84043 L84020 L84046 L84069 L84616 L84002 L84005 L84053 L84072 L84052 L84057 L84008 L84025 L84018 L84031 L84013 L84063 L84075 L84021 L84051 L84070 L84068 L84615 L84004 L84073 L84010 L84085 L84060 L84029 L84024 L84045 Practices NHS GLOS L84058 NATIONAL TOTAL TOTAL L84017 L84042

12 Models of heart failure care pathways The Model of Care should aim to ensure people receive the right care, at the right time, by the right team and in the right place.

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14 MDT/HF Specialist Review - Assessment - Management plan

15 v ARNI

16 MDT/HF Specialist Review - Assessment - Management plan - Follow up with HFSN till optimised

17 Management Key Areas u MDT /HF specialist assessment initial management plan &review/discuss complex cases u Optimisation of treatment u Education u Holistic needs assessment rehabilitation u Long term follow up and monitoring Challenges u Resources limited - HFSN - Use of alternative non specialist nurses u Role of primary care -Knowledge and experience - Demise of QOF - Re-referral - Access to MDT - Primary care Chronic disease models both generic and CVD

18 Clinical Indicator HF1 HF2 Achievement QOF results 2015/16 Practices with a register of heart failure patients %of patients with a diagnosis of heart failure confirmed by echocardiogram or specialist assessment QOF Heart failure Performance 99.4% Exception reporting 95.02% 4.39% HF3 %of patients with LVD treated with ACE/ARB who tolerate therapy and for whom there is no contraindication 99.17% 14.62% HF4 % of patients with LVD currently treated with ACE/ARB additionally treated with beta blocker or recorded as intolerant or having a contraindication 92.59% 16.10% Overall prevalence 0.76%

19 Commissioning and (?levers for) change u Bureaucratic and occasionally idiosyncratic organisations u Proposed CCG outcome indicator sets NP/Echo and 2 week follow up in acute heart failure u Best practice tariff/national Heart Failure audit u Clinical programme groups u STPs - Support 5 years forward view - NHS Rightcare - National and local champions u Community services ICT,RR, IV therapies, Community clinical specialist teams

20 Commissioning organisations Sustainability and Transformation plans : u 44 geographical footprints on which plans are based u 5 year plan u improving quality and new models of care u improving health and well being u improving efficiency u identify priorities and develop plans to deliver within budget u more integrated care with NHS working more closely u No metrics directly related to heart failure

21 Place built around needs of popltn not the individual organisations Joint working with social care and engagement of communities Encouraging self care New care models stroke services in London

22 NHS Right care NHS RightCare makes sure local health economies: u Deliver the right care in the right place at the right time u make the best use of resources offering better value for patients, the population and the tax payer u understand how they are doing by identifying unwarranted variation between demographically similar populations u get talking about the same stuff about healthcare rather than organisations u focus on the areas of greatest opportunity by identifying priority programmes which offer the best chances to improve healthcare for populations u use tried and tested processes to make sustainable improvement to care to reduce unwarranted variation.

23 Commissioning organisations and (?levers for) change u Bureaucratic and occasionally idiosyncratic u Best practice tariff/national Heart Failure audit u Proposed CCG outcome indicator sets NP/Echo and 2 week follow up in acute heart failure u Clinical programme groups u STPs - Support 5 years forward view - NHS Rightcare - National and local champions u Community services ICT,RR, IV therapies, Community clinical specialist teams

24 Commissioning organisations and (?levers for) change u Bureaucratic and occasionally idiosyncratic u Best practice tariff/national Heart Failure audit u Proposed CCG outcome indicator sets NP/Echo and 2 week follow up in acute heart failure u Clinical programme groups u STPs - Support 5 years forward view - NHS Rightcare - National and local champions u Community services ICT,RR, IV therapies, Community clinical specialist teams

25 GLOS Heart Failure service u Community HF service u population u 8WTE HFSNs,3 GPSI S, 0.5 WTE Cardiac physiologist u No NP access u Seamless integration with secondary care.. u 2015 Audit 821pts seen - 59% Primary care u Length of time with service - Mean 8months - Median 6months u Medication - ACE/ARB 88%; - BB 78% - MRA 49% u One year mortality 9.5%

26 Thank you! any questions?