Scottish Government Modernisation Agenda BACPR Conference 2016 Frances Divers Cardiology Nurse Consultant NHS Lothian Scotland SG Clinical Champion CR
The aim of this presentation: Provide an overview of the direction of travel for CR in Scotland Discuss the SG CR Clinical Champion role Describe the process, key findings and recommendations following a scope of CR provision across Scotland Discuss the SG national priorities for service improvement in light of the findings Share some local developments and initiatives from individual health boards
Spread of CR services across Scotland 14 individual Health Boards CR service attached to each HB CR teams core multidisciplinary staff Governed by BACPR Standards Local Managed Clinical Networks National CR steering group Cardiac Interest Group for Scotland (CRIGS)
Same challenges (not exhaustive) Reduced health Funding competing priorities Constant drive to save money Increase in numbers going through service no extra resource Advances in cardiology interventions and treatments Diverse patient groups Multi morbidity agenda Patient expectation Make-up of core CR teams challenge deliver standards Lack of robust outcome measures
National levers for health care delivery Healthcare Quality Strategy - person-centred, safe and effective care The 2020 vision for Health And Social care services. Heart Disease Improvement Plan 2020 CR Vision BACPR Standards
Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation The BACPR Standards and Core Components for Cardiovascular Prevention and Rehabilitation
Standards and 7 Core Components Emphasis on: Patient-centered approach Biopsychosocial focus Multidisciplinary team work Health behaviour change and education at core of all components Recognition of the importance of audit and evaluation
Core Components 1. Health behaviour change and education 2. Lifestyle risk factor management Physical activity and exercise Diet Smoking cessation 3. Psychosocial health 4. Medical risk factor management 5. Cardio protective therapies 6. Long-term management 7. Audit and evaluation
Promoting Excellence in Cardiovascular Disease Prevention and Rehabilitation Standard 4 Cardiac rehabilitation should include early assessment of individual patient needs in each of the core components, ongoing assessment and reassessment upon programme completion
What do we mean by modern cardiac rehabilitation? Modern CR is menu-based and patient centred, and provides a pathway across the 7 stages from diagnosis to long term management. Patient presentation 0 Identify and refer patient 1 Manage referral and recruit patient 2 Assess patient 3 Develop patient care plan 4 Deliver comprehensive *CR programme 5 Conduct final CR assessment 6 Discharge and transition to long term management Patient discharged Sharing cardiac rehabilitation information (education) and long-term management strategy with the patient *CR = cardiac rehabilitation *From DH Commissioning Pack: Service specification for cardiac rehabilitation 2010
Heart Disease Improvement Plan August 2014 Priority 4: Heart Disease Management and Rehabilitation Actions: 1. Modernise cardiac rehabilitation services. 2 Develop anticipatory care programmes for patients with heart disease. 3. Develop condition and wellbeing self-management programmes for patients with heart disease.
2020 CR Vision all patients with heart disease should be supported by CR to live longer, healthier and independent lives CR will be delivered by an integrated, clinically competent, multi-disciplinary team with a central focus on a specialist assessment providing an individualised programme of care to improve outcomes.
Individualised Programme of Care should be: Tiered case management approach with a range of options The length of programme should be determined by need Promote independence and socialisation Early and strong focus on behavioural change Tele-health options should be considered Specialist Assessment should be: Based on patient need rather than diagnostic categories Early in the patients journey Undertaken via a variety of methods including tele-health
Role of Clinical Champion Appt Dec 2014 the aim: Take forward the modernisation CR agenda Carry out a scope of CR services across Scotland Promote the 2020 Vision as new way of working Encourage HB to align service improvements to the 2020 Vision Identify areas of good practice and share across the country
Aim of the scoping exercise: Inform the SG and the national advisory committee for heart disease of an up to date picture of CR delivery in Scotland. Show current position of how we were doing as a Country but also individual HB in respect of delivering and meeting the BACR Standards Share areas of good practice with the CR community in Scotland Identify gaps or particular challenges Recommend priority areas to be taken forward
How did we do it? Self assessment tool mapped to BACPR Standards developed All Health Boards were asked to complete the tool informal process to stimulate discussion among the team Individual Health Boards visited between May September 2015 Meeting lasting 2 3 hr with CR team members Resulting in in-depth discussion around the completed tool and opportunity to add other information about their individual service Heart Disease Improvement Plan benchmarking criteria previously used was adopted as the monitoring tool
What were the findings Motivated, enthusiastic and well experienced staff All programmes reported using a model based on a health behavioural change approach but heavily weighted towards exercise and disease specific education All HB reported delivering seven core components of the BACPR Standards however menu was determined by the skill-mix and knowledge of the core team Particular gaps in dietary and psychosocial elements
Key findings (cont) ACS and surgery continue to be the core businesses but evidence of inclusion of PCI and other patient groups All HB reported carrying out an individual assessment however wide variation in the approach and timing Overall lack of robust data collection and outcome evidence to show effectiveness of interventions leading to self and long term management Wide variation of funding and staffing attached to individual service, with no apparent formulae
Recommendations CR programmes should adopt a consistent health behavioural /goal setting approach to the assessment process All programmes should give equal emphasis to all seven core components aligned to the needs of individual patients building better links with other agencies out-side the NHS. All CR staff to have access to up to date training with the aim of equipping core staff with the necessary skills/knowledge and competence to undertake an individual patient assessment in line with the BACPR Standard and 2020 CR Vision. At a national level SG to support the identification and delivery of appropriate psychosocial training again for core staff. SG should support and encourage CR programmes to travel in the direction of non-medical prescribing to reduce cardiovascular risk There should be clearly defined outcome measures based on self management that are meaningful for CR services in Scotland
Three work streams to be taking forward were around: CR Assessment process Outcomes measures Psychosocial training Work currently being funded from the heart disease improvement fund. Development of an assessment tool Dr Iain Todd NHS Lothian Development of a PROM Dr Janet McKay NHS A&A Psychology Training Dr John Sharp Golden Jubilee Glasgow
Assessment tool: Where are we now Work with Edinburgh University to develop interactive version of tool Pilot on 4 NHS Health Boards Evaluate tool Plan to work towards integrating into local management systems Outcome measures: PROM ready for validation - local health board (A&A) Pilot within other health boards Identifying national agreed outcome measures National indicators Psychosocial training Work with NHS Education Scotland develop model based on motivational interviewing and behavioural change Build on work already being done by our HF colleagues
Local developments and innovation Predictors of attendance at cardiac rehabilitation (CSO funding) - NHS Tayside Multi-morbidity project NHS Ayrshire & Arran Pockets of non medical prescribing across Scotland Activate Your Heart on-line CR programme - NHS Lothian/Forth Valley NACR feasibility study NHS Lothian House of Care - NHS Lothian
Lothian House of Care Collaboration project Model to support self/long term condition management Underpinned by shared decision making between HC Provider and patient Partnership between NHS, social care and third sector The aim is to encourage adoption of the house of care approach to help people to experience a collaborative, person-centred care Supported by SG and BHF focussing on people with or at risk of cardiovascular disease NHS Lothian one of early adopters very early stages
House of care 2 staged approach aim of patient being better prepared and informed leading to better engagement and better long term outcomes 1 st visit Information gathering/sharing Individual CR assessment Discussion around understanding of diagnosis and lifestyle responsibilities What matters to patient/what do they want or need from CR Between visits Preparation for next consultation Patients better informed Engage in own management Provision of information based on outcome of assessment, individual need and choice 2 nd consultation Joint decision making Agreed goals and action (care plan) Patient better informed and prepared for 2 nd visit - tel Review how things are going/what s important to patient Joint care planning/share ideas Discuss CR options Develop care plan
House of care pilot NHS Lothian Intention is to use the approach around the assessment process 4 members of the clinical team will be part of the pilot using the 2 staged approach on 5 patients each (may have to increase numbers) During the trial period the patients will still be offered conventional rehab Data will be collected in response to agreed actions and goals of individual patients Data will be evaluated for emerging themes CR event to share findings and discuss next steps, inviting colleagues from NHS and other outside agencies How will this go watch this space Our hope is that it will provide valuable information which will influence the future of CR delivery.
Applying Evidence to Practice Key Messages: Committed to improvement and providing a service that is fit for purpose Patients should be at the heart of decision making with assessment and intervention based on individual need CR should support patients to self manage their condition Work with colleagues outside NHS to address the integration agenda Continue to share areas of development and innovation through local networks, BACPR and beyond #bacpr2016
Thank you for listening Any Questions? 27