Project Name: West of Scotland (St Luke’s Medical Practice) - Heart Failure Audit and Medicines Optimisation
Project Summary:
The Collaborative Working Project (CWP) with St Luke’s Medical Practice within NHS Lanarkshire has three main aims:
1. To identify known patients with heart failure with reduced ejection fraction (HFrEF) in each general practice and optimise their current heart failure (HF) medications in line with local HF guidelines within the primary care setting.
2. To identify suspected, but currently undiagnosed, HF patients and refer such patients via the NHS Lanarkshire Heart Failure Diagnostic Pathway for formal diagnosis via echocardiogram.
3. The review and update of HF registers within the practice will provide an improved benchmark from which to proactively manage HFrEF patient care.
Project Overview
To achieve the aims listed above, Novartis will procure, contract, and pay third-party provider, Interface Clinical Services, to deliver the following activity:
Heart Failure Prevalence Improvement Service:
- Proactive case finding to improve the records of prevalence of HF by identifying patients with a confirmed diagnosis or evidence supporting a diagnosis of HF who do not appear within the primary care register:
- prioritisation of identified patients according to likelihood of diagnosis;
- support of the appropriate clinical coding of identified (and future) patients through provision of clinical code directories aligned to current NHS business rule-sets.
Heart Failure Risk Management:
- Provision of a proactive risk management tool, and GP practice education in its use, to support the stratification of patients with a diagnosis of HF and perform a baseline evaluation of patient care with respect to, among others, best practice guidelines and HF quality standards including:
- HF population demographic composition (age/sex);
- the number of recommended HF care processes provided within the preceding 12 months;
- current level of HF management;
- potential drivers for poor HF outcomes;
- co-morbidities and markers associated with poor outcomes in HF;
- urgent care encounters with respect to HF (A&E, GP out of hours).
Pharmacist-led HF patients’ notes virtual review:
- Support services to GP practices aiming to improve the management of patients with HF via pharmacological and non-pharmacological interventions according to, among others, current best practice guidelines and GP practice defined treatment pathways and in defined cohorts of patients:
- supporting GP practices to improve the management of patients with HF through note review to identify opportunities for optimisation of therapies licensed for HF and care in line with current best practice guidelines, HF quality standards, local pathways and GP practice defined management strategy;
- provide written educational support to patients to improve health literacy within the context of HF.
Interface Pharmacist-led patient facing clinics for HF patients:
- Support services to GP practices aiming to improve the management of patients with HF via pharmacological and non-pharmacological intervention to, among others, current best practice guidelines and GP practice defined treatment pathways and in defined cohorts of patients:
- supporting GP practices to improve the management of patients with HF through note review to identify opportunities for optimisation, and conduct the first optimisation step if appropriate of therapies licensed for HF and care in line with current best practice guidelines, HF quality standards, local pathways and GP practice defined management strategy;
- provide written educational support to patients to improve health literacy within the context of HF;
- Health care professionals within the practices will be able to attend Interface Pharmacist-led clinics for the purposed of shadowing and upskilling.
Planned Milestones:
| Milestone | Description |
|---|---|
| 1 | Identification of integrated patient pathway |
| 2 | Initial project set-up with third party provider |
| 3 | Heart Failure (“HF”) prevalence improvement service and Heart Failure: provision of a proactive risk management tool, and GP practice education in its use |
| 4 | Pharmacist-led HF patients’ notes virtual (or in-person as required) review |
| 5 | Pharmacist led HF patient face-to-face review clinic |
| 6 | Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary |
Expected Benefits:
Anticipated benefits to patients
- Improved access to diagnosis and treatment
- More equitable and consistent care and access to care
- “Care Closer to Home” potential
- Enhanced experience for patients and their carers who live with HF
- Opportunity to prevent traumatic HF decompensations and hospitalisations
Anticipated benefits to the organisation
- The review and update of HF registers within the 6 practices will provide an improved benchmark from which the practices can proactively manage HF care,
- Increase the overall quality of care and improve equity of access to primary and specialist care for patients with HF,
- Access to shadowing of Interface Clinical Services pharmacists will allow improved knowledge and competence of existing NHS staff to better understand and manage HF,
- Opportunity for other practices in Scotland who are conducting similar projects to connect to share best practice and amalgamate learnings in order to develop an ‘HF Toolkit’, which may inform ongoing redesign and workforce planning at a national level through Heart Failure Hub Scotland.
Anticipated benefits to Novartis
- Further opportunities for the appropriate use of HF licensed medicines in line with local guidelines, including Novartis’ medicines
- Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisations
- Opportunity to facilitate the development of a HF Toolkit, which highlights the need to standardise HF databases and patient care.
Start Date & Duration: Circa July 2024 for 7 months
UK2408063185