HAVE A HEART PAISLEY LEARNING TEMPLATE Project 13: Improving the Patient Pathway The developing professional links and networks element of HaHP was subject to both external independent evaluation and internal project based monitoring and evaluation. The learning points contained in this template are taken from internal project evaluation reports only. These reports consisted of monitoring data collation and a reflective session held by the project area subgroup. The main source of information for this document was ‘Have a Heart Paisley – Summary Internal Evaluation Report’ which was a collation of all the key points from internal evaluation reports written during Phase 1 of HaHP. It is recommended that reference be made to the original reports for further information and to understand the full context of how the various conclusions were drawn. These reports are contained under the ‘List of Outputs’ section which can be found after the Learning Outcomes section of the website you are using. Introduction / Background: • One of four LHCC (Local Health Care Co-operative) associated projects • The aim was to improve the patient pathway by developing effective linkages leading from the community, through the primary care/secondary care continuum and on into tertiary care where appropriate. Central to the process was the existence of a supportive, informed framework operating throughout the community and of which the patient feels a part – which are the locality networks. This has involved: o Raising awareness through the media of local press and radio o Improved links with community networks o Establishment of Primary Care/Secondary Care continuum Key Source Report: • McMahon, S & Swift J (Ed), (2004) Have a Heart Paisley – Summary Internal Evaluation Report, Have a Heart Paisley (http://www.phis.org.uk/hahp/key.asp?itemid=170) Learning Outcomes: • Practices for data collection need to be standardised and involve training for staff collecting this data in order for any cross practice or setting feed to be useful for a centralised database. • The use of a Heart Health Liaison nurse with the specific remit of supporting General Practices to establish electronic registers of CHD patients (including diagnosed angina) was vital as part of the development of the CDR. This post also provided links with Secondary Care services which supports the Primary Care/Secondary Care interface with respect to the Patient Pathway, and staff training in the area of heart health. The evidence to date for the effectiveness of this post in facilitating improved secondary prevention included: The establishment of new clinics in eight practices; 11 practices operating electronic patient recall systems; and 100% (4238) of CHD patients in practices being invited for review. • Software was provided for the Cardiology Department at the RAH to enable the provision of print- outs of data from 24-hour blood pressure monitors used by practices. The print outs were subsequently returned to patients’ GPs. This arrangement circumvented the need for outpatient clinic referrals. Whilst this service was established to enable patient to access the service more quickly, it was also anticipated that it would also reduce the number of referrals and hence waiting time for Cardiology Department out-patient clinics. The waiting times for outpatient appointments dropped to one week from 10 weeks in Aug 2001. This reduction in waiting time may not have been completely attributable to BP service, but could also be reflective of a general downward trend in waiting times for all outpatient clinics. • A ‘Heart Health Nurse Promoter’ initiative was started during the first quarter of 2001. Six G Grade district nurses and health visitors who volunteered for the role were supported through provision of back fill staff to free them up for part of their week to promote HaHP activity and generate public health work in accordance with HaHP's objectives. Examples of work undertaken were giving talks and support to community groups, community BP and health checks at local public events, participating in public health conferences and supporting the development and delivery of the Paisley Heart Award. • The Heart Health Nurse Promoters led community based blood pressure checks supported by the community nursing team. Up to Nov 2003 there were 11 recorded community health events where community nurses checked a total of 678 volunteers’ blood pressure, targeting health events allowed staff to access people from a range of deprivation categories, On average, about 30% of those checked had elevated blood pressure readings, a proportion of those with elevated readings were already being treated for hypertension (i.e. condition supposedly being controlled) and participants were keen to discuss aspects of heart health with staff carrying out the checks. • The District Nursing Team piloted the use of palm-top computers in Paisley in 2003. Patient medical and lifestyle data was collected and passed to Central Data Repository (CDR). This initiative not only enhanced data collection for CHD patients, but also afforded Renver Trust the opportunity to test a shift from paper-based to electronic data collection within community nursing. There were a number of difficulties with the programme centred around coding, and use of the software (Torex) and paper based recording was still required until the problems could be resolved. • As a result of a three cycle programme questionnaires being distributed to GTN users within pharmacies to test their knowledge of their condition and their medication. Patient knowledge about the preventative uses of aspirin was greatly increased with dramatic improvements evident by the third cycle - e.g. 44% rising to 84% knowing that GTN could be used preventatively. Flyers with one or two bullet points given to patients with prescriptions during third cycle were reported as having “tremendous impact” and 430 patients were identified for inclusion in practice CDR’s. • At September 2003, 75% (n=78) of community nurses had completed a compulsory ‘Nutritional Awareness’ training module. • The pattern of fewer men than women engaging with health services was observed by Heart Health Nurse Promoters and echoed in statistics from community projects. A multi-agency men’s health action group was convened with lay representation to explore views on developing a specialist men’s health service. The Action Group commissioned and organised a public consultation to establish what Paisley men perceived as health needs. The consultation took place in June 2003 and involved 358 men; 309 of whom completed questionnaires and 49 participated in face to face interviews. The key findings of the consultation were that: - The key health issues of concern to men were cancer, diet, smoking, alcohol, sleep, weight and exercise - Stress caused by work, family, finances and unemployment was identified as a health concern - Important features of a specialist service would be short waiting times, accessible locations, flexible opening times and staff who took time to listen - A men’s health service could be utilised for; general check ups, cholesterol and BP checks, cancer screening, sexual health and weight management - Gender of staff wasn’t an issue - Most would prefer to be seen in a medical setting. • The nurse led patient pathway also supported the co-ordination of referrals to and after care with respect to the new menu-based cardiac rehabilitation programme. The protocol was developed by a working group of key staff from Primary and Secondary Care. The pathway guidance formalised links back to GP practices from secondary care for long term follow up. Research had previously shown that this is the stage where CHD patients tend to slip through the services net. • The redevelopment of the care pathway between Primary and Secondary Care provided extended support for up to one year for patients eligible for rehabilitation and registered with a GP in Paisley. This was protocol led and was provided by over 100 local health visitors, district nurses and practice nurses over 13 general practices (See Projects 10-13 for more details). • The Heart Renewal project created stronger links with Primary Care providers of CR and allowed support for all eligible patient groups. Professionals across the sectors reported more regular communication and were far more confident that they were providing evidence based and consistent support. • The Heart Renewal project has resulted in considerable improvements in the capacity of community staff to provide evidence based CHD management. • Staff from both the Primary and Secondary care sectors felt they had been stakeholders in the patient pathway during development and implementation. • The staff felt that dedicated posts, dedicated premises and the team dynamics were essential to the successful delivery of the project. In particular the location of the core team within a single area facilitated rapid communication and action. The co-ordinator’s joint role between secondary and primary care was considered key whilst the continuity of personnel was seen as critical to the achievement of so many targets in a relatively short timescale. • Within the pre-five sector, the creation of a dedicated post to develop physical activity programmes made a substantial input on practice across establishments. There was also partnership working with primary care health visiting staff on a joint initiative to support consistent approaches to the development of physical activity in the 18 months – 3 year old age group.