Project Name: ASCVD and Lipid GP-led Primary Care Model of Care – Collaborative Working Project

Project Summary:

The Collaborative Working Project (CWP) is structured such that a multi-disciplinary health professional team will provide tailored care for patients, aligned with the Primary Care Network (PCN) Contract Direct Enhanced Service) DES and the Locally defined Cardiovascular plans.

The main objective of the CWP is to improve the quality of care for patients and support the early identification, review, and medical optimisation of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner. Novartis will contract with Haxby Group Practice.

The CWP will be led by a General Practitioner alongside a multi-disciplinary team; including Healthcare Assistants and Administrative Support aiming to achieve the following within the specified timeframes outlined in the below milestone table:

  1. Identification of sub-optimally treated ASCVD patients who are not achieving lipid levels as specified in local guidelines
  2. Identification of ASCVD patients who have previously not tolerated or refused alternative lipid modification therapies  
  3. Review of treatment options and decision on next steps in collaboration with ASCVD patients
  4. Assess defined project patient cohort on a case-by-case basis, offering counselling and therapy optimisation where appropriate
  5. Early identification of at-risk patients who have not had intervention in their health and wellbeing 
  6. Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated  
  7. On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably

Planned Milestones:

  1. Lipid Management pathway/protocol development
  2. Collection of baseline data, in line with the Project Outcome Measures & Data Collection table
  3. Collection of 3 months clinical activity data & Project Review meeting to discuss project progress. 
  4. Collection of 6 months clinical activity data & Project Review meeting to discuss project progress. 
  5. Project progress discussion across PCNs within locality.
  6. Collection of 9 months clinical activity data & Project Review meeting to discuss project progress. 
  7. Collection of 12 months clinical activity data & Project Review meeting to discuss project progress. 
  8. Development of business case
  9. Analysis of CWP data, submission of Final CWP Report, Submission of Outcomes Summary 

Expected Benefits:

Anticipated benefits for patients:

  • Improved access to lipid management care leading to optimal diagnosis and management of ASCVD treatments.
  • Enhanced experience and counselling around ASCVD with ongoing management of the condition.
  • Improved access to appropriate medication for suitable patients to preserve health and prevent long-term events
  • Easier access to lipid management care closer to home in the primary care setting
  • The additional capacity will provide additional time and support for lipid management, focusing of patients who may have previously not attended GP appointments or been lost to follow-up. This help to level health inequalities within the practice and, ultimately, in a wider setting.

Anticipated benefits for partner organisation:

  • Increased proportion of ASCVD patients reviewed by primary care
  • Increased proportion of ASCVD patients receiving expert and timely review closer to home
  • Reduction in ASCVD referral rates to secondary care
  • Increased proportion of patients receiving guideline-directed pharmacotherapy
  • Insight into benefits of novel primary care led lipid management clinics and demonstration of benefit via development of business case for substantive funding
  • Support aligned to NHS Long Term Plan, CDVPREVENT, and Network Contract DES
  • Opportunity to show the impact of the CWP to create lasting change in lipid management within the Haxby Group Partnership 

Anticipated benefits for Novartis:

  • Increased proportion of ASCVD patients reviewed by primary care
  • Increased proportion of ASCVD patients receiving expert and timely review closer to home
  • Reduction in ASCVD referral rates to secondary care
  • Increased proportion of patients receiving guideline-directed pharmacotherapy
  • Insight into benefits of novel primary care led lipid management clinics and demonstration of benefit via development of business case for substantive funding
  • Support aligned to NHS Long Term Plan, CDVPREVENT, and Network Contract DES
  • Opportunity to show the impact of the CWP to create lasting change in lipid management within the Haxby Group Partnership 

Start Date & Duration: November 2022 – 15 months

UK | November 2022 | 557364

Project Name: ASCVD and Lipid GP-led Primary Care Model of Care – Collaborative Working Project

Completion Date: 1 March 2024

Outcome Summary:

A comprehensive lipids review of all the highest risk patients across the practice was performed. The practice has optimised the care for these patients, which should have lowered their cardiovascular risk and lead to a reduction in CV events in the coming years. 

Key Project Outcomes Data:

The proportion of patients with established CVD reaching lipid optimisation, and thus risk minimisation, increased from 14.2% Dec 2022, to 36% by March 2024. (CVD Prevent data).

Quote from Partner:

“The lipid optimisation project has been invaluable in reducing risk of our high risk CVD population in primary care, particularly in hard to reach groups. The project facilitated time to proactively contact and review patients, and should improve cardiovascular outcomes in the highest risk demographic population. 

It has also promoted lipid and cardiovascular risk factor modification in general, within the clinical workforce culture, and facilitated access to available treatments for patients”

James Read - GP Partner | Director of Prescribing and Medicines Optimisation

Conclusion:

All the high risk patients across the practice have been reviewed and have had their lipids optimised as far as possible. The CWP helped the CW Partner develop a culture of treating and minimising cardiovascular risk factors, and patients have access to an embedded system that will achieve this for them. The CWP will now focus on capturing new high risk individuals, and optimising primary preventative measures. 

FA-11331020 | October 2024