CVD Risk Assessment and Intervention Pathway

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CVD Risk Assessment and Intervention Pathway
North of England Cardiovascular Network, October
2008 Richard Healicon, StR Public Health, NHS
County Durham.
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Agenda

• Why was this project undertaken?
• Patient Pathway.
• Practice Plans.
• Future state.

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Why was this project undertaken?

• Narrowing the gap requires a step change in the
  PCTs approach to CHD. Without this new
  approach, the life expectancy gaps between the
  PCTs and England and within the PCTs will remain
• Inconsistent pathways currently operating in
  isolation
• Inconsistent READ codes and data templates
  create gaps/overlaps and the potential for
  patients at risk of CVD to be missed/double
  counted
• Varied methods for screening patients in/out for
  diabetics/ hypertension
• Different CVD Risk calculations being used across
  4 different practice software systems, 86
  practices in total
• Practices using different methods for calling
  patients in for screening causing, at times,
  confusion and alarm. Leading to high DNA rates
• Confusion regarding roles and responsibilities
  within the pathway

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Project Objectives

• To produce a single definition of CVD risk and
  the level of risk that will be treated
• Establish consistent utilisation of a CVD risk
  register (MSD Toolkit) in operation across County
  Durham and Darlington, that will identify the
  target audience requiring intervention to prevent
  the onset/further development of CVD
• Establish as agreed pathway of care to be offered
  to residents across County Durham and Darlington.
  Pathway will be developed based on evidence of
  best practice with appropriate clinical input
• Preventative action needs to be focused upon the
  most deprived areas with the highest rates of CVD
  and lowest hospital admissions
• Develop a Service Level Agreement with primary
  care to ensure the effective delivery of the FULL
  CVD pathway

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Practice Plans

• Demonstrate ownership and leadership
• Identify key personnel
• Confirm current baseline data of practice
  population
• Confirm practice clinic time dedicated to CVD
  assessment and intervention
• Identify training needs

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Future State

• One CVD risk register used by all practices
  across County Durham and Darlington
• Anonymous data accessed remotely by PCT to report
  QoF and AOP time efficient for PCT and practice
  staff
• Data generated will map health inequalities and
  enable proactive service planning and delivery
• Social marketing will ensure service is meeting
  the needs of the target audience and DNA rates
  are at a minimum value added
• Protocols implemented using National Screening
  Committee guidelines for vascular disease
• Clear roles and responsibilities for staff within
  CVD pathway
• PCT quality assured training programme designed,
  delivered and implemented for all staff within
  CVD pathway
• AOP spend on budget to increase capacity within
  practices
• LES agreement with practices weighted for
  practice population on CVD high risk register.
  Outcome focused measuring movement from estimated
  risk to actual risk and subsequent appropriate
  referral into lifestyle intervention and/or drug
  therapy

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Thanks to Key Stakeholders

• Roger Haydon
• Andrea Brown
• Rob Wade
• Richard Woodhead
• Nicholl Loyd
• Louise Pinkney
• Joseph Chandy
• Jill Simpson
• David Britton
• Diane Woodall
• Mandy English
• Claire Mathews
• Iain Miller
• Barbara Healy
• Lee Mack
• All PBC Chairs and Groups

• Dr Tricia Cresswell
• Dr Neil OBrien
• Dr Stewart Findlay
• Dr Ahmet Fuat
• Dr David Russell
• Dr Dinah Roy
• Helen Metcalf
• Michelle Coglan
• Russell Watkins
• Karen Jones
• Katherine Humby
• Louise Unsworth
• Ian Morris
• Carol Hardy
• CHD Specialist Nurses