Welcome and Introductions Peter Carpenter
Acute presentation 14/03/18 Dr Hugh McIntyre
Acute Heart Failure Timeline
Acute Heart Failure Timeline Andrew Lansley speech to the BMA annual conference "just two weeks ago, I saw a programme which embodies everything I ve been talking about today - clinicians taking the initiative to improve their services, to improve quality of care, access to information and patient outcomes measuring their performance - not against national targets - but against their own standards, and working to improve the quality of the service they provide
Acute Heart Failure Timeline August 2010 Heart Failure EQ Programme 4 measures (LV function evaluation, ACEI or ARB for LVSD, Discharge Instructions, Adult Smoking Cessation) 100% Heart Failure Appropriate Care Score Composite Quality Score 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15
Acute Heart Failure Timeline March 2014 Collaborative Local Discontinuation of CQUIN Plateau in performance Measures? Utility - smoking NHFA specialist input, optimal meds and ward correlate with better outcome National context Acute HF CG 187 tariff 5 year planning: National audits Aligning EQR with NHFA Relevance
Acute Heart Failure Timeline April 2015 to date ACS & CQS since 2015 for KSS Trusts involved in the Heart Failure programme NHFA Aligned Tariff Outcomes Dashboard 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-2015 May-2015 Jun-2015 Jul-2015 Aug-2015 Sep-2015 Oct-2015 Nov-2015 Dec-2015 Jan-2016 Feb-2016 Mar-2016 Apr-2016 May-2016 Jun-2016 Jul-2016 Aug-2016 Sep-2016 Oct-2016 Nov-2016 Dec-2016 Jan-2017 Feb-2017 Mar-2017 Apr-2017 May-2017 Jun-2017 Jul-2017 Aug-2017 Sep-2017 ACS CQS Linear (ACS) Linear (CQS)
Best Practice Tariff NHFA / HES data target is 70% Specialist Input target is 60% *Both must be achieved to obtain the BPT* Highlights 17/18 Q1 & Q2 6 of the 8 Trusts met the BPT criteria All met Specialist Input KPI 6 met data target 628k of a potential increased income of 816k achieved One Trust missed out on ~ 83k One Trust missed out on ~ 106k
Outcomes For information Not patient level (HES aggregate) One of the biggest achievements throughout the course of the programme is the reduction in the crude mortality rate. Across KSS there are 50,000+ patients with Heart Failure. As a rough estimate if all patients with HF were admitted, 1000 less would die in hospital in 2017 as opposed to 2013. 10,640 patients with HF have benefitted from the NHFA care bundle measures since they were adopted in April 2015
Dashboard
Next? Data /Outcomes Tidy the NHFA / HES data gap STP (sustainability and Transformation Plans) CEC (Clinically Effective Commissioning) Atlas of Variation Right Care GIRFT (Getting it right first time)
But
PROMS results symptoms in the last 2 weeks Q1b) Difficulty walking 1 block on level ground - 277 responses: Q8b) Difficulty working or doing household chores - 273 responses: Severe 16% None 19% Much 32% None 27% Much 23% Slight 21% Moderate 20% Some 21% Q9) difficulty during daily physical activities? - 276 responses: Moderate 21% Lots / Cant 28% None 13% A bit 24% Some 35%
Tube Map
Thanks to you to Jen to Fats & Daniel to Justin
Refreshment break 11:30 12:00
Community heart failure dashboard update June 2017 December 2017 Dr Richard Blakey Atrial Fibrillation and Community Heart Failure Lead, Kent, Sussex & Surrey Academic Health Science Network
EQ / AHSN Timeline January 2010 snowy meeting The Hawth Crawley March 2010 appointed community HF lead April 2010 HF EQ into community June 2010 WSPCT LES?implemented Aug 2010 NICE CG108 Oct 2010 NTproBNP Jan 2011 Sir John Oldham Neighbourhood Care Teams Jan 2011 Changes to HF structure - Kent 4/2011 50/50 community/acute HF nurse E.Sx 8/2011? BHF IV diuretic nurse Apr 2013 Change QOF coding from LVD to LVSD 11/2016 Sussex Community take over North of East Sussex 2017 Standardised EF cut off Surrey 2017 ESBT Cardiology pathway re-design
Community HF nurses Band 4 to 7 Area 2010 2017 Surrey 5.5 8.2 Kent 18 17.8 East Sussex 5.5 8.5 West Sussex? 4.6 3 Brighton? 0 2
HF Nurses / GP HF registers (proven LVSD) EQ Baseline data Mean dose/max HF dose 2011 Heart Failure Nurses N = 350 GP registers n = 498* ACE/ARB 57.6% 48.7% Beta-blockers 42.4% 29.0% *12 GP surgeries
Summary 53% of patients seen within 2 weeks for the period April 2017 to December 2017 37% on at least a 50% dose of ACE/ ARB 28% on at least a 50% dose of BB
ACE/ ARB Figures fairly static for April 2017 - December 2017 (suggests that there isn t much improvement to be made having already come so far)
BB Similar story for BB as for ACE/ARB. Appears improvement has plateaued
The Goldilocks Dilemma Community Measures dose of ACE/ARB and BB Remove the measures? Change the measures? Or are they just right?
Atrial Fibrillation and anti-coagulant split Population with AF has increased to 39% for period April 2017 December 2017 Also, the %age on an anti-coagulant has also improved over the same period to 89% Warfarin remains the most popular choice followed by Rivaroxaban then Apixaban
AliveCor and Heart Failure AHSN has received 560 AliveCor devices to distribute across Primary, Community and Secondary care for AF identification Distribution to be prioritised to those users most likely to encounter un-diagnosed AF with high CHA2DS2-VASc score Users to report back newly identified AF Quick view of QRSD Algorithm being developed for QTc
East Sussex AliveCor Results to date 182 ECGs sent 126 new cases of AF reported 33 from Hastings practice 1; 16 new AF 26 from Hastings practice 2: 14 new AF If extrapolated across both CCGs would be >600 new cases detected Narrative from GPs didn t know I was supposed to tell you founds loads of AF use it all the time Any other way of finding out success of the use of AliveCor?
AliveCor cost effectiveness 126 new cases of AF detected and reported to me for 12,000. 95 per new AF detected Cardiology 1 st OPA 16/17 = 166 x MFF For the two practices in Hastings: 17,000 population 5 devices ( 300) 30 new AF detected = 10 per case detected!
Long term conditions focusing on Chronic Kidney Disease CKD is the 4 th most common LTC amongst the KSS community HF population since this programme began in June 2015
Sick day rules Latest advice from Dr Ed Kingdon, AKI lead for AHSN Still no consensus on sick day rules or how to implement withdrawal and restarting HF medication
Referral Received to Assessment within 2 weeks trend since programme was updated in June 2015 The overall trend is a decline in the %age of patients seen within 2 weeks of initial referral However, in the current reporting period (April 2017 August 2017) there is a slight increase in the trend All of the points for the monthly referral to assessment %age falls somewhere between 50-80% which suggests that even though there are month to month changes they aren t dramatic enough to not be of normal variation
Where does Heart Failure feature for Primary care from April 2018?
NICE Proposed CCG Outcome Indicator Set Diagnosis, assessment and monitoring 1. Adults presenting to hospital with new suspected acute heart failure have a single measurement of natriuretic peptide 2. Adults admitted to hospital with new suspected acute heart failure and raised natriuretic peptide levels have a transthoracic Doppler 2D echocardiogram Organisation of care 3. Adults admitted to hospital with acute heart failure have input within 24 hours of admission from a dedicated specialist heart failure team 4. Adults with acute heart failure have a follow up clinical assessment by a member of the community or hospital based specialist heart failure team within 2 weeks of hospital discharge
Further Proposed Areas for HF Quality Assessment 6 monthly reviews Survey of primary care and pharmacy Local HF services Primary care involvement in HF management Review of medicines optimisation post hospital discharge Raising the priority of heart failure with STP decision makers
Sustainability & Transformation Partnership s (STPs) (Formerly Sustainability & Transformation Plan s) 1 3 2 4 The NHS and local councils have formed partnerships in 44 areas covering all of England, to improve health and care. Each area has developed proposals built around the needs of the whole population in the area, not just those of individual organisations. There are 4 STPs that cover the Kent Surrey Sussex region. 1. Frimley Health and Care STP 2. Kent and Medway STP 3. Surrey Heartlands STP 4. Sussex and East Surrey STP STPs are a way for the NHS to develop its own, locally appropriate proposals to improve health and care for patients
CCG PREVALENCE NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 1.13 NHS HASTINGS AND ROTHER CCG 1.05 NHS COASTAL WEST SUSSEX CCG 0.88 NHS SWALE CCG 0.86 NHS THANET CCG 0.86 NHS MEDWAY CCG 0.75 NHS HIGH WEALD LEWES HAVENS CCG 0.73 NHS HORSHAM AND MID SUSSEX CCG 0.72 NHS SOUTH KENT COAST CCG 0.70 NHS CANTERBURY AND COASTAL CCG 0.66 NHS WEST KENT CCG 0.65 NHS EAST SURREY CCG 0.61 NHS ASHFORD CCG 0.60 NHS CRAWLEY CCG 0.58 NHS DARTFORD, GRAVESHAM AND SWANLEY CCG 0.58 NHS GUILDFORD AND WAVERLEY CCG 0.55 NHS NORTH WEST SURREY CCG 0.53 NHS BRIGHTON AND HOVE CCG 0.53 NHS SURREY DOWNS CCG 0.52 NHS SURREY HEATH CCG 0.51
CCG EXCEPTION NHS CRAWLEY CCG 5.88 NHS HORSHAM AND MID SUSSEX CCG 7.42 NHS CANTERBURY AND COASTAL CCG 7.49 NHS ASHFORD CCG 7.69 NHS GUILDFORD AND WAVERLEY CCG 7.97 NHS SURREY HEATH CCG 8.06 NHS EAST SURREY CCG 8.16 NHS NORTH WEST SURREY CCG 8.38 NHS BRIGHTON AND HOVE CCG 8.49 NHS HIGH WEALD LEWES HAVENS CCG 8.55 NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 8.93 NHS DARTFORD, GRAVESHAM AND SWANLEY CCG 9.15 NHS MEDWAY CCG 9.32 NHS SOUTH KENT COAST CCG 9.40 NHS SWALE CCG 9.50 NHS WEST KENT CCG 10.09 NHS HASTINGS AND ROTHER CCG 10.37 NHS THANET CCG 10.59 NHS COASTAL WEST SUSSEX CCG 10.65 NHS SURREY DOWNS CCG 11.44
CCG %LVSD ACE/BB NHS DARTFORD, GRAVESHAM AND SWANLEY CCG 83.01 NHS NORTH WEST SURREY CCG 82.88 NHS MEDWAY CCG 81.51 NHS SWALE CCG 79.79 NHS HASTINGS AND ROTHER CCG 79.46 NHS CRAWLEY CCG 78.57 NHS SURREY HEATH CCG 78.46 NHS WEST KENT CCG 77.90 NHS EAST SURREY CCG 77.78 NHS SOUTH KENT COAST CCG 77.01 NHS HORSHAM AND MID SUSSEX CCG 76.92 NHS THANET CCG 76.13 NHS CANTERBURY AND COASTAL CCG 76.02 NHS GUILDFORD AND WAVERLEY CCG 75.86 NHS ASHFORD CCG 75.60 NHS BRIGHTON AND HOVE CCG 75.56 NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 74.90 NHS COASTAL WEST SUSSEX CCG 73.79 NHS HIGH WEALD LEWES HAVENS CCG 72.87 NHS SURREY DOWNS CCG 71.18
Kent, Sussex & Surrey HF and LVSD prevalence 2009/10 v 2016/17 HF 09/10 LVD 09/10 HF 16/17 LVSD 16/17 Register 29,677 14,461 43,589 10,882 Percentage 0.66 0.32 0.92(+40%) 0.23(-28%) % LVSD receiving ACE +BB Number treated for LVSD ACE + BB 42.1% 65.4% 6,093 7,120
Numbers LVSD treated ACE/BB PCT v CCG 2009/10 v 2016 v 2017 2009/10 2016/17 BRIGHTON AND HOVE PCT / CCG 280 215 (-23.2%) ESDW / EHSCCG + HWLHCCG 544 609 + 168 = 712 (+31%) HASTINGS AND ROTHER PCT / CCG 408 329 (-19%) SURREY PCT / ES+SD+SH+NWS+G&W WEST SUSSEX PCT / CWS + C + H&MS 1051 227 + 221 + 59 + 316 + 180 = 1003 (-4.6%) 1300 967 + 144 + 275 1386 (+6.6%) KENT 2510 3241 (+29.1%) QOF CODING CHANGE 2013/14
Even the best of us need updating and refreshing with so much to know.
Red Flags 56 year old with suspected heart failure Little English Struggling with SOB Murmur - likely aortic stenosis Surgery been discussed in Bulgaria NTproBNP 8,334 ng/l BP 100/88 Ramipril started
95 yr old Longstanding AF CKD3b with proteinuria? (but no ACR since at least 2010) SOB and leg swelling Ramipril 10mg / Bisoprolol 10mg / Diltiazem 180mg XL OD NTproBNP 6,532ng/L Weight Pale. 60Kg BP 100/60 heart rate 70 AF, few bilat basal creps Creatinine Clearance 19ml/min. No Hb since 2013. Plan: no echo, wean off ramipril 24 hr ECG
KSS AHSN ICHOM Heart Failure PROMS Pilot Frances Scott & Ishtar Al-Shammari Heart Failure Collaborative 14 March 2018
Ted 80 years old HF for 15 years Retired Allotment Reading Cooking
What is PROMS Patient Reported Outcome Measures? Used in clinical care (e.g. assessing health status and needs of patients and quality of life Format used usually by questionnaires
Why use PROMS with Heart Failure Patients? Help to monitor o patient progress o help professionals and patients discuss health issues with each other o and/or help to improve the quality of health services KSS AHSN worked with ICHOM using a standard set of PROMS questions adapted to use in KSS local setting
Outcome measurement drives value improvements for all stakeholders Key stakeholders Transparent, highquality outcomes data Patients will choose their provider based on expected outcomes and their share of the cost Clinicians will improve quality of care by comparing performance and learning from each other Hospitals will differentiate into areas where they deliver superior outcomes at competitive prices Value Payers will negotiate contracts based on results, not volume, and encourage innovation to achieve those results Life science will market their products on value, showing improved outcomes relative to costs
ICHOM was formed to catalyze the transformation to Value Based Health Care ICHOM History Our mission Founded in 2012 by thought leaders with the desire to use outcome measurement to unlock the potential of value-based health care. ICHOM is a nonprofit Independent 501(c)3 organization Idealistic and ambitious goals Global focus Engages diverse stakeholders Our mission Unlock the potential of value-based health care by defining global Standard Sets of outcome measures that matter most to patients across a wide range of medical conditions, and driving the adoption and reporting of these measures worldwide Value = Patient health outcomes achieved Cost of delivering those outcomes
ICHOM plays several roles along the journey that will enable value-based health care: our strategic agenda ICHOM defines internationally recognized Standard Sets of outcomes and related case-mix factors ICHOM will provide riskadjusted international benchmarks on outcomes by medical condition ICHOM will become a methodological partner with media to publish ratings based on ICHOM outcomes Define Standards Measure outcomes Benchmark on outcomes 1 Collaborate to improve value 1 Establish outcomes transparency Develop value-based payment models VBHC ICHOM facilitates adoption and implementation by sharing knowledge and supporting proof-of-concept ICHOM will enable cooperation to improve value by establishing value collaboratives ICHOM will engage payers and governments to realign financial incentives and promote transparency Core mission of ICHOM Enabler role Current focus 1. We are exploring the inclusion of resources data in benchmarks but the methodology is to be determined
ICHOM organizes Working Groups to define Standard Sets of outcomes we recommend all care providers track ICHOM facilitates a process with international physician and registry leaders, patient representatives and methodologists to develop a global Standard Set of outcomes that really matter to patients
We have completed 23 Standard Sets, covering >50% of the disease burden as defined by WHO Our current 23 Standard Sets 2016-2017 commitments 1. Inflammatory arthritis 2. Oral health 3. Congenital upper limb anomalies 4. Paediatric facial palsy 5. Type II diabetes 6. Atrial fibrillation 7. Overall adult health 8. Diabetes In discussions to launch 1. Mental health package 2. Overall child health 3. Overall cancer 4. Pediatric epilepsy 5. Multiple sclerosis 6. COPD 7. Morbid obesity Numbers not representing prioritization/ likelihood
ICHOM is helping providers across the globe measure outcomes Direct capacity-building support Lighter-touch networked support Ad-hoc advisory support and workshops Coronary Artery Disease Implementation Community Partner with innovative providers to pilot outcomes measurement in their institutions and develop local capacity to scale Provide guidance and action items to global institutions implementing Standard Sets with a goal of benchmarking Kick-off implementation in more experienced organizations by introducing Standard Set content Currently supporting 43 organizations
ICHOM and KSS AHSN have completed the pilot phase of the project Key Tasks Preparation Diagnostic Roll Out Measurement Establish project team and governance structure Establish local clinician buy-in Assess and define scope of project Assess IT and informatics infrastructure within pilot sites Perform a gap analysis of what data is collected versus what isn t Determine and process map pilot implementation sites Secure additional IT/Information platforms to address data gaps Secure PROM licenses for Standard Set as required Deploy data capture solution Pilot data collection with part of dataset Assess Pilot period Refine Workflow and IT systems using PDSA cycles Scale up to implement full dataset Troubleshoot full dataset issues & quality assure data Begin to measure and analyze full dataset Change Management Copyright 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 56
Outcomes measurement will lead to multiple benefits for private and public hospitals Identify and disseminate best practices Direct measurements and comparisons will enable identification and dissemination of best practices Benchmark sites/teams and drive continuous improvement Demonstrate superior outcomes Anchor reputation in facts Attract new patients in areas of excellence, also internationally Potential to charge a higher price for improved quality of care (depending on country/regulation) Enhance Management capabilities Take informed decisions for staff promotion and/or investments (based on outcomes achieved) Adapt delivery models to achieve similar outcomes at lower cost Be prepared for more transparency/new models Get prepared for value based payment models Quantify your performance and be ahead of the trend for more public transparency Demonstrate superior performance to obtain maximum reimbursement from value based payment models Starting outcomes measurement now will allow you to shape the global trend rather than merely respond
After a successful pilot, Aneurin Bevan University Health Board is scaling Standard Set implementation across the organization Background Aneurin Bevan University Health Board partners with ICHOM in 2015 to support translation of VBHC theory into practice Impact on Outcome 9 months into implementation, capture of demographic data reached 100% and Parkinson's PROMs reached 88% ICHOM Parkinson Standard Set Percent completion in ABUHB program Initial pilot: to implement one condition Parkinson s disease in one clinic Supported by an empowered and cross functional Steering Committee Board, IT, finance, clinical representation Dedicated project management team Fit-for-purpose IT solution Workflow revisions: patients complete PROMs in waiting area clinicians review data prior to consultation Post pilot, VBHC Team formed to provide central coordination of roll out of VBHC implementation across the organization Scaling implementation to four more condition lung cancer, heart failure, lower back pain, cataracts Organization-wide VBHC courses used to build awareness Falls Healthrelated quality of life Hospital admissions Ability to work Cognitive and psychiatric functioning Non-motor functioning Motor functioning Basic demographic information Patient-reported baseline information treatment variable information Clinicial-reported outcomes Patient-reported outcomes, non-motor Patient-reported outcomes, motor Patient-reported outcomes, PDQ8 100 72 54 23 88 88 88 Arora J, Lewis S, Cahill A. Implementing ICHOM s Standard Sets of Outcomes: Parkinson s Disease at Aneurin Bevan University Health Board in South Wales, UK. London, UK: International Consortium for Health Outcomes Measurement (ICHOM), March 2017 (available at www.ichom.org)
Sweden's best practice adoption in AMI has helped them achieve better outcomes and use of resources than UK Background Risk-adjusted data from national Swedish and UK quality registries compared Sweden Impact on Outcome 30-day mortality Standardized mortality rate 2 37% higher 30-day mortality in the UK compared to Sweden 7.6% 1.0 10.5% 1.37 Primary PCI 3 59% 22% UK β blocker at discharge 4 89% 78% Compared care and outcomes for all UK and Swedish AMI patients during 2004-2010 Better uptake of evidence-based treatments in Sweden than the UK were shown to lead to lower AMI mortality rates Impact on Resources ALOS, AMI >40% shorter hospitalization time in Sweden 20-44% 10 0 5.6 10.2 5.2 9.8 2004 2005 5.1 9.2 4.8 8.8 4.7 8.6 2006 2007 2008 Sweden UK 4.5 8.1 2009 Year Source: Chung et al, Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK, The Lancet, Jan 23, 2014. OECD data
Brazil ANAHP Heart Failure Community Implementation ANAHP: National Association of Private Hospitals in Brazil 8 sites participate in the program (Sao Paulo, Porto Alegre, Belo Horizonte, Rio de Janeiro) Highlights 1. On site Project Manager coordinates the implementation between the 8 hospitals 2. Once the Implementation Community program is finished, each hospital will have the knowledge to move on to implementing the next Standard Sets 3. Implementation community support internal benchmarking between the participating sites, in the next phase sites plan to benchmark outcomes internationally
KSS Pilot.
Pilot Scope Initial pilot was for 9 months (Feb to Oct 2017) 4 Community HF Teams Kent Community Healthcare Trust, East (Whitstable) Kent Community Healthcare Trust, West (Sevenoaks) East Sussex Healthcare Trust West (Eastbourne) East Sussex Healthcare Trust, East (St Leonards)
Pilot - Aim To gather questionnaire data for a minimum of 50 patients per team (200 in total) To review this data comparing to Enhancing Quality outcomes data where the data was related. Shortness of Breath Odema/Swelling Questionnaire aimed to assess quality of care delivered to (All Cause) patients from the patient s perspective.
Results Total number of questionnaires given out is 500 Total number of questionnaires returned is 281 Estimated return rate 55% (skewed) Most robust sample - Kent Community Trust West - Return rate for 37%
Clinical Outcomes PROMS results What is it like living with Heart Failure? A serious, chronic condition that tends to gradually get worse over time. Eventually it can shorten patients life. Weight gain Shortness of Breath Coughing & Wheezing Swollen ankles, legs or abdomen Tiredness Need to urinate at night Dizziness Feeling frightened Depression Anxiety Rapid heart rate Loss of appetite
What did the patients report feeling 2 weeks post discharge and following first visit from HF Nurse? Physical All providers - Q1b) Walking 1 block on level ground - 277 responses: 0 = Extremely limited, 42, 15% 5 = Limited for other reasons or did not do the activity, 18, 6% 1 = Quite a bit limited, 47, 17% 4 = Not at all limited, 58, 21% 2 = Moderately limited, 55, 20% 3 = Slightly limited, 57, 21%
What did the patients say they felt having Heart Failure? Social All providers - Q6) Over the past 2 weeks, how much has your heart failure limited your enjoyment of life? - 275 responses: 0 = It has extremely limited my enjoyment of life, 40, 14% 4 = It has not limited my enjoyment of life at all, 65, 24% 1 = It has limited my enjoyment of life quite a bit, 62, 23% 3 = It has slightly limited my enjoyment of life, 57, 21% 2 = It has moderately limited my enjoyment of life, 51, 18%
What did the patients say they felt having Heart Failure? Social All providers - Q8a) Hobbies, recreational, activities - 272 responses: 0 = Severely limited, 53, 20% 5 = Does not apply or did not do for other reasons, 31, 11% 4 = Did not limit at all, 28, 10% 1 = Limited quite a bit, 59, 22% 3 = Slightly limited, 50, 18% 2 = Moderately limited, 51, 19%
What did the patients say they felt having Heart Failure? Psychological All providers - Q7) If you had to spend the rest of your life with your heart failure the way it is right now, how would you feel about this? - 275 responses: 0 = Not at all satisfied, 66, 24% 4 = Completely satisfied, 25, 9% 3 = Mostly satisfied, 62, 23% 1 = Mostly dissatisfied, 59, 21% 2 = Somewhat satisfied, 63, 23%
What did the patients say they felt having Heart Failure? Psychological 11a) Little interest or pleasure in doing things? - 272 responses: 3 = Nearly every day, 39, 14% 2 = More than half the days, 19, 7% 0 = Not at all, 130, 48% 1 = Several days, 84, 31%
What did the patients say they felt having Heart Failure? Psychological All providers - Q6) Over the past 2 weeks, how much has your heart failure limited your enjoyment of life? - 275 responses: 0 = It has extremely limited my enjoyment of life, 40, 14% 4 = It has not limited my enjoyment of life at all, 65, 24% 1 = It has limited my enjoyment of life quite a bit, 62, 23% 3 = It has slightly limited my enjoyment of life, 57, 21% 2 = It has moderately limited my enjoyment of life, 51, 18%
Do these results surprise you?
How does Heart Failure burden of symptoms compare to other long term conditions? Study comparing burden of symptoms of HF patients with advanced lung or pancreatic cancer Both conditions had similar scores but patients with more severe heart failure had a greater number of physical symptoms, higher depression scores and lower spiritual well-being than patients with advanced cancer. Bekelman, Rumsfeld, Havranek, Yamashita, Hutt, Gottlieb, Sydney and Kutner, Symptom Burden, Depression and Spiritual Well-Being: A Comparison of Heart Failure and Advanced Cancer patients - Journal of General Medicine (2009)
Challenges/Lessons Learnt Need clarity and understanding of all data items and processes Acknowledge HF teams are resourced differently and different roles complete multiple tasks which impact on the process of data collection Teams were at times overstretched to take on the additional requirement of the pilot having an impact on the data collection but did manage to upload data at a later date
Challenges/Lessons Learnt Questionnaires posted to patients deemed to be more successful Single point of co-ordination to record questionnaire sent and returned (Kent Community West team) Where possible integrate process with existing processes (ie. Posting care plan include PROMS questionnaire)
Next Steps Recommend to teams to utilise PROMS questionnaires as part of their quality audit Link into Quality programmes at Trusts Pilot teams to make recommendations to see if there are any opportunities to change and improve care Review pathway Review care plan to reflect Include PROMS results in MDT review Do patients need more psychological support? Work with ICHOM to benchmark results with other national and international pilots
Questions? Frances Scott frances.scott@nhs.net Ishtar Al-Shammari i.alshammari@ichom.org kssahsn.net ichom.org
Lunch break 12:30 13:30
An introduction to the Health Service Engagement team
Ensure that everyone in the UK with CVD has access to high-quality, integrated health and social care services 81
Health Services Engagement Team Make the case for change at a health system level to improve evidence based CVD care eg working with RightCare, AHSNs, Public Health England Use BHF best practice portfolio and evidence based practice to challenge variation in care and identify sustainable solutions that respond to the challenges of the health system in quality, efficiency and effectiveness Act as a catalyst for change by convening senior decision makers and practitioners to identify challenges, opportunities and solutions to improve CVD care through communities of practice Educate and empower - signpost to training and resources for health professionals to optimise delivery of the best care to people living with or at risk of developing CVD (BHF Alliance)
Local success stories Learning from teams who have used the collaborative to make a change
Celebrating Success: Using data to make improvements Sarah Young Nurse Consultant Cardiology On behalf of the BSUH team
The BSUH HF team - now 2 x HF Consultants Dr Ellery Dr Coombs 3.6 WTE HF nurses Nurse Consultant Cardiology Consultant pharmacist 0.6 WTE HF MDT co-ordinator Wider MDT cardiology and non cardiology teams, cardiac physiologists echo and pacing, palliative care, clinical psychologist, arrhythmia nurse specialists, cardiac rehab 5 non-medical prescribers Local protocols for non-prescribers
What we do Nursing team receive on average 100 referrals/mth Inpatients Online referrals HF ward rounds (nursing review in between) Tues and Thur RSCH average 10-12 pts / round Mon and Thur PRH average 4-5 pts / round HF MDT Tues and Thur RSCH average 9 pts discussed on Tues, smaller number on Thursday Thur at PRH average 7 pts discussed
Outpatient referrals Education re HF and self management strategies Uptitration of HF meds Admissions avoidance Access to MDT re devices, specialist support 29 nurse-led clinic slots / week Outpatients Inpatients - early follow up after discharge Diuretics and renal function As above
Sacubitril valsartan since Aug 2016 AKI and heart failure Short stay patients ED NT pro-bnp RAHFC Acute cardiologist Ambulatory care Hospital@Home
Other aspects of the service RAHFC on both sites timely echo Ferinject and recruiting for IRONMAN Ultrafiltration Devices CRTP/D Standard ICD information including deactivation Leadless pacemakers Subcutaneous ICD s Remote monitoring clinic / congestion alerts
Cardiology patients referred for advanced heart failure assessment Waiting list (two with LVAD) 4 Transplanted - 2017 3 Referred 2 Removed 1
But not always like that. Inequity of care 15/16 Q1 EQ data RSCH PRH Specialist input 85% 49% Echocardiography 82% 58% Referral to HFNS (LVSD) 87% 50%
Addressing this inequity Took a long time. Started talking about this 5 years ago Tertiary centre, 2 hospitals Failed EQ targets (RSCH achieved, PRH not achieved) Trust asked questions EQR team support in the Trust for service redesign Pathway mapping March 2015 On line referral Additional manpower
Business case Cardiovascular directorate priority 2015-16 Business case started March 2015 Cost effective with devices, Best Practice Tariff, reduced hospital admissions Used EQ data to show inequity between RSCH and PRH sites
Difficulties No new money Chicken and the Egg Trust support / commissioner support Achieved Trust support (July- Sept) first secondary to commissioner support Local commissioners in Mid Sussex Education for primary care Admissions avoidance RAMU Specialist commissioners re devices NHS England
Business case signed off Jan 2016 Money available from April 2016 10 PA HF Consultant 1.0 WTE HFNS PRH 0.6 WTE MDT co-ordinator (admin) 1.0 WTE Cardiac physiologist (echo) 1.08 WTE Lab staff
What it means Access to Specialist care for all HF pts across the Trust Additional HF Consultant cover across both sites Additional 1 day in the lab for devices HFSN on site at PRH All HF admissions RAMU for admissions avoidance Onward referral to community HF nurses or FU in nurse-led HF clinic
Implementation at PRH HFNS 1.0 WTE HF admin co-ordinator 1 day / week Consultant HF ward round twice / week MDT with community HF team once / week Work with medical and nursing teams On line referral all cause HF Liaison with cardiac physiologists and prioritisation of echo s
PRH EQ data
National HF audit 2016-17 provisional RSCH April 16-March 17 (n=403) Echo 79% 69% ACE/ARB 93% 86% Beta Blocker 92% 83% MRA 76% 72% Specialist input 76% 65% HFNS referral (LVSD) 82% 79% PRH April 16-March 17 (n=204) Survival to discharge 357 (88%) 178 (87%)
More work to do 1.0 WTE - Cover for leave 0.25 WTE Band 6 HF nurse (1 yr secondment) Non LVSD patient follow up
Thank you to the PRH team!
Integrated Heart Failure Team Sarah Terry Specialist Heart Failure Nurse
Our population West Population approx. 184,290 and 23 GP Practices East Population approx. 183,000 and 33 GP Practices
The Integrated Heart Failure Team In 2004 three Community Heart Failure Specialist nurses were employed as part of the BHF project to recruit heart failure nurses across the country. The community nurses joined an existing acute heart failure specialist nurse. This formed an integrated heart failure team that crossed the secondary care and community boundary. Current team structure A mix of full/part time staff and includes: Acute Heart Failure Specialist Nurses Community Heart Failure Specialist Nurses Heart Failure And Device Specialist Nurses (West) 50/50 Acute/Community Heart Failure Specialist Nurses Heart Failure HCA s
Referrals and Caseload Average 108 referrals to the team each month. Referrals for all cause heart failure. Referrals can be made by: email (to a generic central email) automated referral from the hospital system to the email post face to face telephone. Average caseload varies between 20 75. Systmone patient record system.
Key aspects of our roles Identify new admissions with known or potential heart failure. Ensure a confirmed diagnosis of heart failure by BNP testing and echo. All patients treated for heart failure with a confirmed diagnosis are discharged with a Transfer of Care document, follow up plan and appointment with a heart failure specialist nurse. Reducing hospital admissions and length of stay Medication titrations Education and Support End of Life care Education for staff Ongoing data collection and electronic patient record Weekly MDT and heart failure ward rounds Onward referrals e.g. Cardiac Rehabilitation, Breathlessness Clinic
The 6 month review project (East) Why did we make this change? As a team we discharge patients back to GP with open door access. In 2016 we identified that patients with reduced EF (<35%) that had been discharged to GP were a potential group of patients that we could review to revisit possible further medication titration and new indications for CRT. How did we do it? All patients with an EF<35% are added to a calendar for potential review in 6 months. Each month the patients names are reviewed to see if they have already or have pending a review with cardiology, GPwSI or other appropriate professional. If not the patient is invited to attend for review. If the patient has been seen by a relevant person they are added to the calendar in a further 6 months time, this is also the same for those who don t respond. The patients whom respond are asked to have an ECG (as appropriate) and a blood test. They are reviewed in clinic in the normal way.
Outcome 300 225 150 75 0 Patients on the 6 monthly Calander RIP Invite letter sent Responded Required review Ongoing after 1st review Did not result in excessive demand on service Potential to reduce hospital admissions Patients have been identified that are now suitable for CRT We have been able to adjust medications and further titrate as per NICE guidelines
50/50 Role Why did we make this change? Improving patient support in the immediate post discharge period To reduce hospital readmissions and length of stay How did we do it? The nurse meets the patient in hospital and follows them up post discharge, up to 30 days. The patient is reviewed at home usually within a week of discharge and if not within 2 weeks. At 30 days the patient is either discharged to the GP (being added to the calendar for 6 monthly follow ups as indicated) or transferred to one of the community heart failure specialist nurse for further input.
50/50 Outcomes Patients are able to begin to build a relationship with the heart failure nurse prior to discharge Post discharge concerns/problems particularly those that are medication based are identified early The 30 day period allows for the nurses caseload to be lower and more fluid, enabling the flow of patients from hospital to be seen in a timely manner.
IV Diuresis in the community. Increased day case IV diuretics, as appropriate. Continued review of patients with a reduced EF (<35%) every 6 months. Support groups. Equitable access to support for heart failure patients who have CRT therapy.
For more information: Please contact Sarah Terry, Community Heart Specialist Nurse on 01424 857905 or sarahterry@nhs.net.
Local plans for next steps Reflect on your team s next steps
EQ data Single site - Run chart. Median line is middle of data points Multiple sites Line graph. Line for each site and trust total. No median Tuesday, March 20, 2018 118
Roundtable discussion Sit with your team/trust or bounce ideas with the person next to you. 45 minutes (including tea/coffee break) to discuss and plan for your next actions. Think about: What problems do you want to solve? What ideas do you have for doing this? Who else do you need to involve to make this happen? Create an action plan for who will do what and by when in order to get your change into practice Think about what you can do longer term, but also some small actions you can do next week or soon to help you get there.
Discussion Team name: What problems do we want to solve? What ideas do we have for doing this? Who else do we need to involve?
Action plan Team name: Action to be taken By when (in the next week, month, 3 months) By who
Feedback A brief 2 minute summary plan from each group. Remember to grab a tea/coffee.
The future working with the BHF
Award ceremony Celebrating the collaborative s success stories!
Summary and next steps
Thank you Helen O Kelly Health Service Engagement Lead (South East England) okellyh@bhf.org.uk Sian Martin Clinical Development Coordinator martins@bhf.org.uk