Project Proposal template

LTC Commissioning Intentions Project Proposal (DRAFT) Project Objectives      To gain an understanding of the reasons behind the clinical gaps iin blood pressure control, cholesterol control, medicines management and smoking advice identified by the Combined Predicted Model. To reduce identified gaps in blood pressure control, cholesterol control, medicines management and smoking by 80% by March 2010. The scope of this work is gaps for the top 0.5% to 5% of the population. Consolidate good practice To have in place a personalised care plan for all LTC patients within the top 5% risk segment (equivalent to approximately 18, 000 patients) To develop systems that are sustainable and maintain the gap reduction Exclusions The project will exclude patients within the top 0.5% risk segment, many of whom would be expected to be requiring palliative care. Patients who die or move practice during the course of the project will be excluded from the 80% reduction target. Interim milestones Period Quarter 1 DRAFT Smoking advice: check coding Reissue cessation advice annually for all smoking / ex smoking patients Reinforce smoking advice guidance to all GPs Meds management Identify CHD / diabetes patients with gap. Blood Pressure Identify all patients with uncontrolled blood pressure. Prioritise resource according to practice need. Cholesterol Identify all patients with uncontrolled cholesterol Prioritise resource to Smoking advice gap closed. Admin Recall and review system to incorporate annual advice Admin Action plan for all identified patients Admin Map of practices and action plan for closing gap Action Identify practice lead for LTC programme Outcome Lead identified Resource Any practice staff Programme lead Admin and practice lead Consortia lead List of identified patients BP action plan incorporates cholesterol Page 1 of 9 Admin Admin / practice lead D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc Quarter 2 map against BP and med mmt review. Meds Management Complete a medicines review of all identified patients Blood Pressure/ cholesterol Deliver phase one of action plan (top priority 50%) patients Meds gaps closed GP/pharmacist Appropriate treatment initiated for all patients in prioritised practices GP/pharmacist PCP Practice workshop tbc A greater understanding of the reasons for the gaps identified and what is working effectively in addressing these. Pan-Lambeth/PCT Quarter 3 Blood Pressure / Cholesterol Gap closed for all patients in phase one practices GP/pharmacist DRAFT Deliver phase two of action plan (all remaining practices) Appropriate treatment initiated for all patients in phase 2 practices and blood pressure/cholesterol PCP * see note Quarter 4 Blood Pressure / Cholesterol Gap closed for all patients in phase two practices Practice and consortia leads Embed smoking advice Med mmt BP Check Cholesterol check and PCP in all new patient checks Test recall and review system to ensure gaps continually monitored Page 2 of 9 D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc Admin and practice lead and managed. Pan Lambeth group Evaluate impact of programme outcomes and agree future action plan Outcome measures and monitoring arrangements Patients within the top 0.5-5% risk segment will be identified at the start of June. The PCT will provide monthly data (at practice level) for these specific patients for the duration for the project (dependent upon extraction of combined model data). This will include blood pressure, cholesterol, medicines management and smoking advice. The Pan-Lambeth group will be responsible for co-ordinating the submission of monitoring data as outlined below on a quarterly basis. Quarter Q1 Outcome Identified practice lead Patients with clinical gaps identified at practice level and reviewed. Monitoring information List of practice leads Both overall patient numbers with clinical gap and patient level information at both practice and Pan-Lambeth level (see template 1&2) DRAFT Mapping of need (for each clinical gap) by practice Development of consortium action plan to reduce medicines management, cholesterol and BP clinical gaps based on mapping exercise Smoking gap reduced by 80% across all practices Q2 Treatment initiated for those patients with blood pressure and cholesterol gap in the phase 1 prioritised practices Prioritised list of practices Summary of key actions that will be taken (e.g. hypertension clinic targeting particular practices, prescribing advisor to undertake reviews, template development practice nurse training) – to include how resources will be allocated. Overall numbers and patient level at both practice and Pan-Lambeth level (templates) Overall numbers and patient level information at both practice and Pan-Lambeth level (see templates 1-2) Medicines management gap reduced Page 3 of 9 D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc by 80% Update on progress including key actions taken Practice workshop – to gain a greater understanding of the reasons for the gaps identified, what is working effectively in addressing these and sustainability issues *PCP – see notes Blood pressure and cholesterol gap reduced by 80% in Phase 1 practices. Treatment initiated for those patients with blood pressure and cholesterol gap in the phase 2 prioritised practices Narrative provided as part of template 1 Workshop report Q3 Overall numbers and patient level information at both practice and Pan-Lambeth level (see templates) Evaluation proposal developed and submitted to PCT Update on progress including key actions taken Evaluation proposal Q4 DRAFT *PCP – see notes Blood pressure and cholesterol gap reduced by 80% in Phase 2 practices Evaluate impact on clinical gaps Evaluation agreed by NHS Lambeth and responsibilities/deadlines allocated by Pan-Lambeth group Initial report Update on progress including key actions taken *PCP – see notes Evaluation completed Discuss next steps with NHS Lambeth Narrative provided as part of template 1 Overall numbers and patient level information at both practice and Pan-Lambeth level (see templates) Finalised evaluation proposal Q1 Narrative provided as part of template 1 Final report Recommendations made to LTC Programme Board (NHS Lambeth) *The implementation strategy of personalised care plans is currently being developed and will be integrated into this plan when further information is available. Costings Page 4 of 9 D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc To be included as part of action plans (consortium level by 30th June 2009.) The main expenditure for this project will include o Project support pending appointment of BSU posts o NHS Lambeth will provide some project management support (outlined in separate document) on an interim basis. o Project manager (part-time/sessional) – primarily aimed at ensuring clinical engagement and delivery at consortium level o Data analysis support - BSU o Pharmacist – medications review o Implementation of personalised care plans. Costs potentially in additional clinician time to implement. o Remainder as incentive payments to practices on delivery Sustainability o o Data extraction and analysis, continued use of combined predictive model or equivalent – evaluation will inform decision on whether this will be commissioned post March 2010 Workshop in October and final evaluation to review progress and make recommendations for next steps. Risks and contingency plan Risk Clinical engagement – practice sign up No regular monitoring data due to problems with data extraction Actions taken / to be taken DRAFT Drug availability (e.g. current problems with supply of clopidogrel) Patient turnover Late recognition of problems in defining accurately the criteria, rulesets etc Access to combined model longer term Pan-Lambeth group and consortia leads to discuss with practices The PCS issue has been escalated to the ICT steering group. The Care Pathway Redesign Team, Health Dialog and the clinical facilitator team are working with practices to resolve any other issues as quickly as possible. To date the vast majority of practices have extracted data; however this will need to be monitored regularly. Discuss with medicines management team to ascertain scale of the problem Patients that are not with the practice for the duration of the project will be excluded, though they should still be included within monitoring returns, but coded as having left the surgery. Working with the care pathway redesign team to ensure clarity on objectives, exclusions etc. The PCT have commissioned the Combined predictive Model until March 2010. As part of this piece of work the effectiveness of this tool will be evaluated and based on this a decision made on arrangements post March 2010. Page 5 of 9 D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc Progress will be reviewed on a quarterly basis and appropriate remedial action taken. It is likely that further development should continue to optimise this process. Evaluation The following outcome measures will need to be incorporated into the monitoring arrangements from the beginning of the project. Quantitative – desired outcomes - Summary of overall achievement in terms of clinical gap reductions and introduction of personalised care plans Qualitative – desired outcomes - Learning from the project – what worked effectively, what were the challenges/barriers - Greater understanding of the reasons for the clinical gaps initially identified. - Evaluation of the new ways of working that have been put in place to improve management of patients on LTC registers – from both patient and clinical perspective (GPs, practice nurses, community matrons). Qualitative indicators (EuroQoL and PHQ9) will be measured at the start and end of the project for a minimum of 200 patients across Lambeth. - Feedback on personalised care plans – clinical and patient - How practices will ensure that improvements are sustained in the longer term and how this will be monitored - Evaluate usefulness of CPM as a case finding tool - How this project has promoted consistency in practice Name of lead responsible officer: Judy Cook, Adrian McLachlan DRAFT Page 6 of 9 D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc Monitoring template 1 Pan-Lambeth summary (overall numbers) Number of patients with clinical gap End of Quarter End of Quarter End of Quarter 2 3 4 Data Blood pressur e CHD Diabetes Cholesterol – CHD Cholesterol Cholesterol – Diabetes Baseline % reduction in clinical gap Beta blockers - CHD - Heart Failure Medicines management ACEI/ARBs - CHD - Heart Failure - Diabetes Statins - CHD - Diabetes DRAFT Page 7 of 9 Anti-platelets D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc Asthma CHD Smoking Heart Failure COPD Diabetes All patients Narrative - Key actions taken in this quarter - Summary of progress against milestones including any deviations and remedial actions taken - Challenges/lessons learned P C P DRAFT Page 8 of 9 D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc Monitoring template 2 – practice variation (overall numbers on quarterly basis – purpose is to provide indication of variation by practice) Number of patients with a clinical gap MM ACEI/ARBS Beta Statins blockers Practice Consortium Blood pressure Cholesterol Smoking advice PCP *not within CPM report DRAFT Page 9 of 9 D:\Docstoc\Working\pdf\c68cb1c7-e655-4d72-8a8a-1c1599ece856.doc