Cardiovascular disease has shifted from being an acute to a chronic condition, which demands more joined up care pathways, says Chris Annus
A growing number of patients are suffering from cardiovascular disease. Coupled with an ageing population, it means patients are now living with chronic long term conditions that require ongoing care across primary, secondary and tertiary settings.
‘It could take a week for patients to see a cardiologist. Now the team proactively seeks out patients’
Without more joined up care pathways, CVD patients suffer poorer health outcomes and often need hospital treatment that could have been prevented with better self-management and community care.
The British Heart Foundation’s £1m integrated care programme funds innovative models of integrated care across nine NHS sites. It aims to:
- improve outcomes for CVD patients;
- reduce health inequalities;
- reduce unnecessary secondary care activity;
- provide care closer to home; and
- give greater attention to preventative care, earlier identification and supported self-management.
The BHF will use the programme to provide evidence-based examples of how service redesign can effectively integrate care.
An early success story has been the implementation of the pilot at East Cheshire Trust.
Launched in September 2012, the pilot supported East Cheshire to expand its cardiology nurse led service at Macclesfield District General Hospital and link more closely with the community based heart failure specialist nurses. This has created a flexible workforce of full-time nurses who bridge care across primary and secondary settings.
With additional specialist nursing capacity, and redesign of care pathways, the project aims to:
- reduce length of stay in hospital by identifying and assessing cardiac patients and beginning treatment pathways sooner;
- develop a community intravenous diuretics pathway to prevent (re)admissions and provide choice for patients on where to be treated (this British Heart Foundation-designed community based IV diuretics service is now approved by QIPP and available on the National Institute for Health and Care Excellence website);
- upskill health professionals in primary and secondary care, for example training heart failure nurses in angina and atrial fibrillation so they can work with more patients, or patients with comorbidities; and
- place greater emphasis on education for patients and carers to enable them to manage their own conditions more effectively.
Its outcomes included:
- 850 hospital patients seen and assessed since November 2012;
- 390 fewer bed days since April 2013 via the community IV diuretics programme;
- estimated cost savings of £48,750 based on IV diuretics impact alone; and
- length of stay reduced across all cardiac categories (see table below).
Length of hospital stay for cardiac patients (days)
|National average, 2012||East Cheshire average, 2012||East Cheshire average, April-June 2013|
|Non-cardiac chest pain||1.1||2.0||0.9|
Julie Walker, cardiology nurse clinician and project lead, says: “Previously the demands on the department meant it could take up to a week for patients to see a cardiologist. Now the team proactively seeks out patients, we assess them and on going home they have a clear treatment plan, a follow-up date and contact details in case of any problem.”
Challenges for implementation
The following have been identified as common challenges.
- Recruitment: Some sites struggled with recruitment because of the specific nature of the skills required. Sites must factor in the time needed to secure the right staff.
- Networking within the sector: Some sites have experienced professional tensions between nurses funded by the project and non-cardiology consultants they are working with, who are not always comfortable with the extended nurse role. Pilots have found that gaining support from the cardiology consultants involved in the project helps ensure buy-in from staff in other departments.
- Networking across sectors: Some GPs have been unsure about the benefits for them. Pilots have been able to reassure GPs by highlighting the support the pilot provides such as access to consultant expertise or by highlighting the quality and outcomes framework points available by reviewing patients with coronary heart disease.
- Sustainability: Where pilots have included commissioners early, such as on project steering groups, there are indications the service will be commissioned and maintained.
Although the programme is not due to complete until spring 2015, interim evaluations continue to provide robust, evidence based examples of how commissioners can integrate care to improve outcomes for CVD patients with long term conditions and make better use of NHS resources.
Tips for success
The following points are ways to make improvements like the ones East Cheshire made.
- Give yourself time: Recruitment for specific roles can take several months so be realistic and factor this in.
- Get early buy-in from senior medical staff: Our pilot sites have found that where senior cardiology consultants have been involved early on there has been greater understanding of the extended nurse roles.
- Get commissioners on board early: Our pilots are hearing stronger commitments to sustain services where commissioners have been engaged, perhaps via a steering group, from the outset.
- Sell the benefits before you ask for support: Be sure to outline how your project can make life easier for partners before you start asking for their time and support. For example, let GPs know about the access they could gain to expert consultants.
- Cross-train your staff: By ensuring nurses can work with patients with a range of heart conditions, those with co-morbidities will be treated in a more joined up way and the need for multiple, condition specific clinics will be reduced, freeing up staff time.
- Set homework: Increasing focus on educating patients and their carers on what to do outside hospital will help keep patients healthier and happier at home for longer.
Chris Annus is business and service development manager at the British Heart Foundation