Applying the principles of the Five Year Forward View

The British Heart Foundation Innovation Pilots

Simon Gillespie

Ensure that everyone in the UK

with CVD has access to high-

quality, integrated health and social

care services

The Forward View into Action:Co-creating new models of care

• Address local need

• Co-design to accelerate change

• Demonstrate proof of concept

• Prototype that can be replicated elsewhere

Service Innovation Timeline

1980s 1990s 2000 2004 2006 2009 2012 2013 2014 2015

Heart Helpline

Pioneered the model of nurse-led services

2 models of BHF service design on

QIPP website

Heart Failure & IVD Resources CPD Accredited

Heart Support Groups

House of Care

Innovation through

multi-skilling clinical

staff

IntegratedCare

BHF Alliance

FH Nurses

The BHF Integrated Care Pilots

NHS Lanarkshire

NHS Tayside

NHS Fife

East Cheshire NHS Trust

Oxleas NHS Trust

NHS Bristol

North Somerset

CCG

BetsiCadwaladr

UHB

ABM University

Health Board

• £1 million• 9 sites• Independently evaluated

Consistent with 5YFV:

• Multispecialty community providers

• Integrated primary and acute care systems

• Models of enhanced health in care homes

BHF rationale for funding pilot projects

Pump Prime & Test

Hypothesis

Redesign care and support

pathways

Evaluate & build

evidence basePublish and

Disseminate

Spread & Adoption of

Best Practice

Learning & new

hypotheses

Components of Effectiveness

Components of

effectiveness

Clinical effectiveness

SafetyPatient and

carer experience

Cost effectiveness

BHF Pilot with East Cheshire NHS TrustThe Challenge:

• 15.5% increase in emergency admissions for CHD between 2009 – 2011

• East Cheshire fastest growing elderly population in North West

• Chest pain, AF and HF identified as generating greatest no of admissions

• LOS longer than the national average

• Commissions wanted to upskill primary care to deal with demand and reduce duplication of care

BHF Pilot with East Cheshire NHS TrustThe Solution:

• Developed generic cardiology specialist nurse team – expanded remit

• In-reach programme: identifying patients in A&E and Medical Assessment Unit

• New pathways and community clinics for chest pain, AF and Heart Failure and delivering IVD in peoples’ homes

• Joint assessments and care plans for LTCs with diabetes, respiratory, pain management and palliative care teams

• Training and support with social care and care homes

Outcomes and Impacts 1Reduction in LOS (days)

Angina MI AF HF0

2

4

6

8

10

12

14

16

2011-20122012-2013

Outcomes and Impacts 2

In-patient bed days saved: 2391

Saving £1,195,000Cost benefit ratio 1:8.8(for every £1 invested, the NHS saves £8.80)

Example Multispecialty Community Provider for an Integrated Community Cardiac Team

 

Care Co-ordinator - working with

Patient

Cardiac Nurse

Respiratory Nurse

Home Intravenous

Therapy Team

Social Care Team and

Carer Support

Community Mental Health

Team

Palliative Care Team

New patient pathways have moved activity – increased diagnosis and follow-

up care - from acute to primary and community care

Before After

Secondary Care

Primary and community Care

Admission DiagnosisFollow-up

Admission

Follow-upDiagnosis

The British Heart Foundation Innovation Pilots

NHS Tayside

Karen Smith Nurse Consultant Cardiology

NHS Tayside

School of Nursing and Midwifery University of Dundee

BHF Pilot with NHS Tayside The Challenge:

• Review of National CHD standards (Quality Improvement Scotland 2010) highlighted some major shortfalls in arrhythmia management within NHS Tayside

• Three main work streams• Atrial fibrillation • Implantable Devices (ICDs and CRT)• Inherited cardiac conditions

• Opportunity to work in partnership with the teams in primary care to develop and evaluate new models of integrated care improving the patients referral, diagnostic and care pathways and consequently patient experience

• Upskill health care teams

Achievements for AF

• 10 Rapid Access AF clinics per month rolled out across all 3 community health partnerships

• Referrals via Referral Management System and Consultant referral – aim to see within 2 weeks

• Integration of patients with LT arrhythmia management

• Improved patient pathways for DC cardioversion

• Anticoagulation, less cancellations, timely intervention, early review (4 weeks & 6 months versus 4-6 months from cardiologists)

Improvements in Cardioversion

Improved waiting times for procedure

In contrast through the arrhythmia service

Anticoagulation

“instead of having to wait for the cardiologist,…we got pretty quickly the letter about the flutter clinic’ their previous experience highlighted that ‘It just took forever. I can’t remember when you actually got your first cardioversion. I can’t remember. It took months”

“So you’ve got a very defined timeline, rather than…… sitting in limbo waiting on things to happen … And I think the service, that way it’s worked out, for us has certainly been better, knowing full well that that’s the time you’re going to get it done”

“I knew that obviously this is not the best thing to be on. But I was unaware of how intrusive it is as regards the INR readings, going to the clinic, getting a booking at the clinic even, because it’s like a week in advance when it’s really full. So I think that was the next sort of hassle, was getting INR level to the right level, so I could then go for cardioversion”

Quality of life - AFEQT –

Overall score good quality of life, limited disability associated with their AF. Improvements symptoms scores and daily activities @ 6 months

Knowledge –

overall scores 60-70% but still identified areas for improvement in understanding of AF – eg 44% did not know why it was important to take medications – ? impact on compliance

Self management - Patient Activation Measure (PAM)- Underlying knowledge skills and confidence integral to managing one’s own health and healthcare. PAM categorises respondents into one of four activation levels:

Level 1 – Disengaged & overwhelmed

Level 2 – Becoming aware but still struggling

Level 3 – Taking action

Level 4 – Maintaining Behaviours and pushing further

AF Outcomes

Patient feedback – Atrial Fibrillation

“I think I would have felt different if I’d just been left with the consultant cardiologist completely I think…. the old service as regards you felt you were being processed……… But with the change, it probably makes you aware that somebody maybe does care and is looking after your interests. And that’s quite a big change from route number one of being processed to then being an individual that you’ve got this key contact that’s looking after you”

Aim: • To address the gaps in psychological support and provision through

nursing intervention offering pre and post implantation support

• Baseline data - ICD concerns high levels invited to attend review

• ICD concerns – guides clinical consultation , assessment improved over time less number and severity

• Mood - reduced anxiety and depression over time up to 6 months , slight inc again by month 10 ? Shocks delivered

ICD patients

 

ICD- Patient experience: adverse effects

“I mean I think the darkest moments ..goes back to probably the first two years … I could understand how people commit suicide to be honest. I felt there was no point, I didn't feel there was any future at all, I couldn’t think of a future. And of course, people around about you don't really understand this. I am not blaming them, I think it had a quite serious effect”

“I think I more or less withdrew into not living at all. I was sitting outside in my chair with a computer doing routine work on a project which I am doing, I was terrified to go out…..I was feeling so uptight and, that it was changing the rhythm of my heart”

• Regained confidence and Independence • Travelling • Returned to golf• Learnt a new language• Improved relationships within the family

Transformed lifestyle from isolation, high anxiety and multiple admissions

Prevention of admission

“Well the case where I had the VT in the morning, and I phoned and I left a message on ‘the nurse’s’ phone and she got back to me and then it wasn't very long, she got back to me within a couple of hours later. And I could say to her look it has settled down and she knew. I knew that somebody knew…. Otherwise I would have had to have said to myself oh dear, do I phone in, do I go up to A&E the ambulance people on a couple of occasions have been distinctly iffy about taking me”

mean score level 1 level 2 level 3 level 40

10

20

30

40

50

60

70

80

Patient activation Measure

ICDAF

Self Management in AF and ICD patients

Inherited Cardiac Conditions

• Monthly multidisciplinary ICC clinic

• MDT meetings

• Although smallest clinical group have significant support needs

ICC

• Referred following sudden death of family members – father, brother and sister

• Investigation recommended ICD implantation

ICD

• Pre and post device support from arrhythmia nurses

AF • Developed AF • DC cardioversion through arrhythmia service

Integration within services

“Having a heart condition can be a scary time. For me personally, I don't think I would have gotten through the whole thing without fantastic support from the BHF arrhythmia nurses. But it's not just them. There's a whole team of people involved in it….. Everyone you provide support for will have their own story to tell, their own fears…, But without you all providing the support and care that you do so well everyone's journey would be a very lonely one”

Integrated Specialist Nursing Service

 

Patient

Cardiac rehabilitation

Nurse

Arrhythmia Nurse

Heart failure Nurse

Chest pain Nurses

• Integrated into mainstream services

• Opportunity to review & integrate existing nursing roles within specialist nursing team

• Streamline our patients pathway

Independent Evaluation demonstrated:

They are clinically effective

They are safe

They are cost effective

They improve the patient and

carer experience