Docstoc

There are an estimated 295000 people in Bolton that are registered

Document Sample
There are an estimated 295000 people in Bolton that are registered Powered By Docstoc
					                                     Triple Aim
                          Work Programme 2011/12


Practice

Cluster

Marmotised Colour

Practice Manager:

Contact Details:

Triple Aim Team Contact    Lynda Helsby
Details:                   01204 462102
                           Lynda.helsby@bolton.nhs.uk




Triple Aim Programme of Work 2011/12                    Page 1
                                              CONTENTS
Contents                                                         2
Objectives & Background of Triple Aim Programme                  3
                              Project                           Page
Incentive Based Projects
Local Enhanced Schemes                                           4

Provision of Triple Aim data                                     4

Primary Prevention Screening (NHS Health Check)                  6

Primary Prevention Annual Review                                 8

Early identification of Impaired Glucose Tolerance / Diabetes    10

Early identification of Atrial Fibrillation                      13

Early identification of Alcohol Misuse                           15

Best Care Projects                                               17
    Coronary Heart Disease
    Diabetes
    Chronic Obstructive Pulmonary Disease
    Atrial Fibrillation
    Heart Failure
    Chronic Kidney Disease

Improving ethnicity recording of CHD/Diabetes Registers          21

                                        Supported Projects
COPD Screening                                                   22

Cancer Information                                               22

Maternal & Child Health Information                              23

Mental Health Information                                        23

                                      Education Programme
Rolling Programme of Education                                   23

Other
Sign up form                                                     26


Triple Aim Programme of Work 2011/12                                   Page 2
                               Triple Aim in Primary Care

                             Programme of Work 2011/12

Objectives:
Working collaboratively with Primary Care the Triple Aim Programme of work will:

      Promote better health for the people of Bolton, best care for patients, best value for
       money using the resources we have wisely and enhancing the patient experience.
      Support the delivery of high quality, safe and accessible care
      Address the gaps in health inequalities and life expectancy
      Support practices in training and development
      Promote primary healthcare team working to deliver outcomes

To deliver these objectives we will be required to develop a process that includes:

      Integrated analysis and reporting of comparative data
      Multi-disciplinary team working
      Development support for practices including a dedicated programme of education
      Measurement and benchmarking of performance
      Action planning to improve performance
      Appropriate resources.

Background

Bolton has an unenviable position with regard to health inequalities. Life expectancy for
men is 75.7 years and for women is 80.1 years (ONS 2007-09). Whilst evidence shows life
expectancy is improving, people in Bolton on average live 2 years less than in other parts of
the country. To address this position we need to support primary care to target areas that
contribute to an improvement in these statistics. NHS Bolton Strategic Plan (2009-14) has
identified seven high priority areas. These are areas where we need to improve health
outcomes:

      Cardiovascular Disease (CVD)
      Diabetes
      Alcohol related digestive disorders
      Cancer
      Respiratory conditions
      Mental Health
      Maternal and Child Health

The Triple Aim in Primary Care team has developed a dedicated programme of work, to
implement projects that we believe will address these health outcome areas and the health
inequalities.




Triple Aim Programme of Work 2011/12                                                   Page 3
Local Enhanced Schemes

Practices are expected to provide essential and any additional services they are contracted
to provide to their practice population. These incentive schemes outline the additional work
needed by General Practices for their engagement in the Triple Aim programme of work.
The specifications of the schemes are designed to cover the additional work and clinical care
of the patient, all of which are beyond the scope of essential services. No part of the
specification by commission, omission or implication defines or redefines essential or
additional services.

The Triple Aim team will visit practices during April / May to present the work programme.
Practices will need to provide data in relation to the schemes and make available to the PCT
appropriate information on request to enable compliance with the schemes to be validated
and audited.

Timescales:

The schemes outlined in this programme of work will run from April 2011 to March 2012.

The next sections outline the enhanced schemes for 2011/12.

Triple Aim Data Submission

In order to monitor practice performance we will require quarterly information from each
practice. Support will be given to all practices to set up the search criteria, by the Triple Aim
Data Co-ordinator, in an effort to ensure a systematic and consistent approach.

Data will be analysed and returned as a Triple Aim report within one month of data
submission.

Payments will be made as below:

Project                                           Payment
Data Submission                                   10p per patient for 4 data submissions per
                                                  year
                                                  i.e. 2.5p per total practice population per
                                                  quarter.


The data template is attached.




Triple Aim Programme of Work 2011/12                                                       Page 4
Triple Aim Programme of Work 2011/12   Page 5
         PRIMARY PREVENTION - BBHC                                PRIMARY PREVENTION                               PRIMARY PREVENTION - National                                                                             AF
         Health Checks - 40 years +                               Annual Review - 40 years +                       Health Checks - 40 - 74 years                                                                            65 years +
                         PPa            PPb                            PPc              PPd                                           Ppe          PPf           PPg                                                                         AFa         Afb          Afc              Afd

                                     Total no. of
                                                                                                                                                                                                                                              Of those    Of those    Of those    Of those
                                       patients                                       No. of
                                                                  No. of patients                                                                  No. of       No. of                                                                        patients     pulses     patients patients who
                        No. of       40 Years +                                    patients on                                        No. of
                                                                    ≥ 20% risk                                                                   patients   patients who                                                                     aged 65+ checked in      found to have had an
          Practice     patients       <> CVD &                                     PP Register                       Practice       patients                                                                                  Practice
                                                                        on                                                                      invited for  have had a                                                                     how many the last 15      have an    ECG how
         Population   40 Years +      Diabetes                                    who have had                      Population     40 - 74 yrs                                                                              Population 65
                                                                     Primary                                                                   health check health check                                                                   have had a     months     irregular  many have
         40 years +   <> CVD &       who have                                       an annual                      40 - 74 years   <> CVD &                                                                                    years +
                                                                   Prevention                                                                    in last 5    in last 5                                                                    pulse check how many pulse how          been
                       Diabetes     had a health                                  review in last                                    Diabetes
                                                                     Register                                                                      years        years                                                                     in the last 15    are     many have   diagnosed
                                    check in last                                   15 months
                                                                                                                                                                                                                                             months?     irregular had an ECG?   with AF?
                                        5 yrs


Jun-11                                               Jun-11                                           Jun-11                                                                                                  Jun-11


          IGT                                                                                                                                  CVD                                                                                                                COPD
         40 years +                                                                                                                            (includes CHD, TIA, occ CVA, PVD)
                         IGTa           IGTb           IGTc            IGTd             IGTe            IGTf                                       CVDa         CVDb            CVDc            CVDd           CVDe             CVDf                                COPDa            COPDb

                                        No. of                                                        Of those
                                                                                                                                                                                                                               No. of                                                   No. of
                                       patients     Of those                                         patients on                                                                                               No. of
                                                                   Of those                                                                                                      No. of        No. of                      patients on                                              patients on
                                      40 years + patients with                                         the IGT                                                                                              patients on
                         No. of                                patients with a                                                                                               patients on    patients on                   CVD register                                                  COPD
                                       without      a blood                          How many       register how                                                                                           CVD register                                              No. of
          Practice     patients                                 blood sugar                                                                       No. of        No. of      CVD register CVD register                        who are                                               register who
                                    diabetes who     sugar                          patients are     many have                                                                                                with a                                               Patients
         Population   40 years +                                 ≥ 5.6 mmol                                                                    patients on   patients on        taking     with a      BP                 recorded as                                             are recorded
                                     have had a    recorded                          on the IGT     had either a                                                                                            cholesterol                                            on COPD
         40 years +     without                                  how many                                                                       CHD reg       CVD reg       anti-platelets  ≤ 150/90 in                    smokers in                                             as smokers in
                                     blood sugar  how many                            register?     GTT or blood                                                                                          ≤ 5mmol      in                                           register
                       diabetes                                 have had a                                                                                                    in last 15      the last                        last 15                                                  last 15
                                     recorded in have a result                                      sugar in the                                                                                          the last    15
                                                                    GTT?                                                                                                       months        15 months                       months                                                   months
                                      the last 5 ≥ 5.6 mmol?                                            last 15                                                                                               months
                                                                                                                                                                                                                           (last entry)                                             (last entry)
                                        years                                                         months?


Jun-11                                                                                                                              Jun-11                                                                                                             Jun-11

         CKD                                                                                                                                                                                                                                                      CARERS
         18 years
         +              CKDa            CKDb          CKDc            CKDd             CKDe             CKDf          CKDg           CKDh          CKDi         CKDj           CKDk             CKDl           CKDm                                                  CAREa

                                                                                                                                                                                               Total no.      Total no.
                        No. of
                                                                  No. of patients                                                                                            Total no. of          of             of
                    patients 18                                                                                                       No. of
                                                                   on the CKD           No. of          No. of         No. of                   Total no. of Total no. of    patients on      patients on    patients on                                             No. of
                       years +                         No. of                                                                      patients on
          Practice                   No. of                       register who       patients on     patients on    patients on                 patients on  patients on    CKD register     CKD register   CKD register                                          patients on
                    who have a                      patients on                                                                        CKD
         Population              patients with                    have had an       CKD register    CKD register   CKD register                CKD register CKD register     coded with          WITH         WITHOUT                                             practice list
                     creatinine                      the CKD                                                                         register
         18 years +              an eGFR ≤ 60                     ACR recorded        coded as        coded as       coded as                      WITH       WITHOUT           BP to         Proteinuria    Proteinuria                                            who are
                    recorded in                      register                                                                       coded as
                                                                    In last 15         CKD 3a          CKD 3b         CKD 4                    Proteinuria Proteinuria       QOF target     achieving BP achieving BP                                                carers
                      the last 5                                                                                                      CKD 5
                                                                     months                                                                                                    140/85       to NICE target to NICE target
                        years
                                                                                                                                                                                                130/80         140/90


Jun-11                                                                                                                                                                                                                                                 Jun-11


          ALCOHOL                                                                                                                                                                            LIFESTYLE                                                            ETHNICITY
         16 years +                                                                                                                                                                         16 years +
                       ALCOa           ALCOb          ALCOc           ALCd             ALCOe           ALCOf         ALCOg          ALCOh         ALCOi                                                    LIFEa            LIFEb                                    ETHa


                         No. of                                                                                                               Of those
                                      Of those      Of those                                                        Of those     Of those                                                                      No. of       No. of
                       patients                                  Of those              Of those        Of those                           patients who
                                    patients who patients who                                                     patients who   patients                                                                 patients aged patients aged
                       aged 16                                patients who          patients who    patients who                          scored ≥ 20                                                                                                                No. of
                                     have had     scored ≥ 5                                                     scored 16 - 19 who have                                                                  16 years + on 16 years + on
          Practice      years +                                 have had            scored 8 - 15     have had                             how many                                           Practice                                                            patients on
                                     AUDIT C in   how many                                                         how many         had                                                                    practice list practice list
         Population   who have                                AUDIT 10 how           how many       AUDIT 10 how                           have been                                        Population 16                                                         practice list
                                     the last 27   have had                                                        have had a    AUDIT 10                                                                     who are     with a BMI
         16 years +       had                                 many scored             have had      many scored                            referred to                                         years +                                                           with ethnicity
                                    months how AUDIT 10 in                                                           Health     how many                                                                   recorded as   recorded in
                      AUDIT C in                                between             brief advice      between                                 alcohol                                                                                                              recorded
                                    many scored     the last                                                         Trainer      scored                                                                      smokers     the last 5
                      the last 27                                8 - 15?            for alcohol?       16 - 19?                             treatment
                                         ≥5       27 months?                                                     intervention?     ≥ 20?                                                                    (last entry)    years
                        months                                                                                                              services?


Jun-11                                                                                                                                                                        Jun-11                                                                    Jun-11




Triple Aim Programme of Work 2011/12                                                                                                                                                                                                                                              Page 6
Primary Prevention Screening (NHS Health Check)

There are an estimated 30,000 people living in Bolton aged 40 years and over at high risk of
developing Cardiovascular Disease in the next 10 years. We want to identify all these people
so that we can offer treatment and interventions to reduce their risk and improve their
health. We have implemented the BIG Bolton Health Check successfully in Bolton with
almost 75% of the eligible population receiving a Health Check.
The scheme aims to improve this further and ensure 100% of the population are offered a
health check and 90% uptake over the next 5 years in line with the NHS Operating
Framework.

       The establishment of registers of at risk patients in all practices is a standard in the
       National Service Framework for Coronary Heart Disease: 'general practitioners and
       primary health care teams should identify all people at significant risk of
       cardiovascular disease, but who have not yet developed symptoms and offer them
       appropriate advice and treatment to reduce their risks'.

Primary care teams will be better able to offer systematic care to all patients to maximise
their quality of life, to minimise their incidence of disease, and to predict future service
requirements if they have an effective means of identifying (and intervening with) patients
at risk - registers are the means by which these patients will be identified.

The Health Check should be delivered in line with Best Practice Guidance which can be
found at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_097489

Practices will be given individual trajectories for offering and uptake of health checks and
payments capped at this rate.

Where available this scheme can be supported by the Practice Health Trainer by prior
agreement with the service manager. Health Trainer community events will be arranged
throughout the year to support outreach to specifically target the ‘hard to engage’
population. Supported targeted events can also be arranged within practices by contacting
the Health Trainer service manager.

Evidence from the BIG Bolton Health Check suggests that personal contact with patients
encourages a better response rate therefore this scheme assumes practices will contact the
patients personally.

Project                                          Payment
Primary Prevention Screening (NHS Health         £10 per health check (capped at pre-set
Check)                                           trajectory)




The audit requirements will be taken from the quarterly Triple Aim data submission.

Triple Aim Programme of Work 2011/12                                                      Page 7
 Graph Data
                                               Number of patients
                                  Qtr1_1112   Qtr2_1112         Qtr3_1112   Qtr4_1112
 Traj - Offered HC                       56          56                56          56
 Traj - Recd HC                          51          51                51          51
 Cumulative HC carried out               13          24                34          49
 Cumulative HC offered                   15          31                43          62




Triple Aim Programme of Work 2011/12                                          Page 8
Primary Prevention Annual Review (replaces Best Care LES)

Cardiovascular Disease (CVD) is the leading cause of death in England and Wales. CVD
predominantly affects people older than 50. Apart from age and sex, three modifiable risk
factors – smoking, raised blood pressure and raised cholesterol – make a major contribution
to CVD risk. The risk of a future CVD event can be calculated from these risk factors and
people at higher risk identified. Working collaboratively, NHS Bolton and Primary Care have
successfully undertaken risk assessments on almost 75% of the eligible population. We have
identified over 19,000 patients at increased risk (>20%). This scheme aims to ensure that
these patients have an annual review.

Healthcare professionals should discuss CVD risk with the patients, offering support and
treatments to empower them to reduce their risk. Treatment and care should take into
account a person’s needs and preferences, their culture and any physical, sensory or
learning difficulties ensuring effective communication of information.

This scheme is not prescriptive about what the annual review should contain, however:

      Consider referral to practice Health Trainer
      Lifestyle changes including diet, exercise, weight management, alcohol consumption
       & smoking cessation
      Modifiable risk factors should be considered and their management optimised
      Lipid modification therapy.

Further guidance is available from NICE Clinical Guideline 67:

http://www.nice.org.uk/guidance/CG67/QuickRefGuide

Payments will be made to practices, as a Logarithmic Incentive Scheme, for each annual
review undertaken.



Project                                         Payment
Primary Prevention Annual Review                Logarithmic Incentive Scheme – per patient
                                                reviewed:
                                                Payments at £3.30 for 60% achievement
                                                Payments at £3.95 for 70% achievement
                                                Payments at £4.85 for 80% achievement
                                                Payments at £6.15 for 90% achievement

                                                (Full payment scale enclosed)


The audit requirements will be taken from the quarterly Triple Aim data submission.




Triple Aim Programme of Work 2011/12                                                  Page 9
Primary Prevention Annual Review Logarithmic Incentivisation


                                     Primary Prevention Annual Review Logarithmic Incentivisation
                        9.00


                        8.00


                        7.00


                        6.00
  Payment/patient (£)




                        5.00


                        4.00


                        3.00


                        2.00


                        1.00


                        0.00
                               20%    30%      40%     50%      60%     70%      80%     90%        100%   110%




Triple Aim Programme of Work 2011/12                                                                         Page 10
Early identification of Impaired Glucose Tolerance / Diabetes

The overall aim of this scheme is to identify individuals who have Impaired Glucose
Tolerance (IGT), and develop accurate registers enabling NHS Bolton to understand its
prevalence.

Research shows that without any lifestyle or medical intervention, about 50% of people with
Impaired Glucose Tolerance (IGT) will develop type 2 diabetes (accompanied by increased
risk of cardiovascular disease and developing micro vascular complications) within five to
ten years. Progression to Type 2 Diabetes is not inevitable, approximately 30% of individuals
with IGT will return to normal glucose levels. Lifestyle changes have been shown to delay or
prevent the onset of Type 2 Diabetes in people with IGT. This type of intervention has also
been shown to be cost-effective, particularly when targeting those within the IGT
population who are thought to be at highest risk of developing Type 2 Diabetes.

Working collaboratively, NHS Bolton and Primary Care have successfully undertaken blood
sugars on over 75% of the eligible population. We have found that over 33,000 patients
have a blood sugar >5.5. In December 2010 40% of these patients have had a Glucose
Tolerance Test (GTT). This scheme aims to improve this further and ensure 100% of the eligible
population have a GTT as per the protocol, attached.



Payments will be made to practices, as a Logarithmic Incentive Scheme, for each patient
invited for a Glucose Tolerance Test, who subsequently receives the tests.



Project                                           Payment
Impaired Glucose Tolerance Test                   Logarithmic Incentive Scheme – per patient
                                                  called:
                                                  Payments at £2.25 for 60% achievement
                                                  Payments at £2.98 for 70% achievement
                                                  Payments at £3.95 for 80% achievement
                                                  Payments at £5.50 for 90% achievement

                                                  (Full payment scale enclosed)


The audit requirements will be taken from the quarterly Triple Aim data submission.




Triple Aim Programme of Work 2011/12                                                   Page 11
                                 Identification of Diabetes and Impaired Glucose Tolerance
                                                     Regulation Protocol
              Under 40 yrs &                                 Over 40 years
           2 or more risk factors                             Screening                                    History of Gestational Diabete


                           Random venous plasma glucose                                                                    6 week
                                                                                                              Post-natal Venous Plasma Glucose
                                                                                                                    Glucose Tolerance Test

    Result >11.1 mmol/l                        Result                                  Result
     with symptoms or                    5.6 – 11.0 mmol/l                         < 5.6 mmol/l
    2 separate readings
                                                                                                            Normal

                                         Glucose Tolerance Test                           Normal
                                                                                      Repeat random
                                                                                      venous plasma
 Diabete                                                                               glucose every
                                                                                                            Annual Random
    s                                                                                     5 Years           venous plasma
                                                                                                               Glucose
                           Impaired              Impaired           Normal
                             Fasting              Glucose
 Diabete                                                                                                                        ≥ 5.6
                           Glycaemia             Tolerance
     s                                            C11y200                                                            Glucose Tolerance Test
 Register                   C11y300
   with
  annual
  review                3 Years GTT             Annual GTT            Repeat venous
                     If normal after 3       If normal after 1        plasma glucose
                   years, keep patient      year, keep patient                                          Diabetic -       Impaired        Not D
                                                                      every 3 years or                  Diabetes                            An
                      on IFG register,        on IGT register,                                                            Glucose
                                                                     earlier if clinically              Register        Tolerance -        ran
                    with annual recall      with annual recall
                   for Random venous            for Random               indicated                     with annual      Annual GTT          ve
                      plasma glucose          venous plasma                                              review
                                                  glucose




Triple Aim Programme of Work 2011/12                                                                                      Page 12
                                                  GTT Logarithmic Incentivisation
                         8.00


                         7.00


                         6.00


                         5.00
   Payment/patient (£)




                         4.00


                         3.00


                         2.00


                         1.00


                         0.00
                                20%   30%   40%      50%     60%      70%     80%   90%   100%   110%




Triple Aim Programme of Work 2011/12                                                                    Page 13
Early Identification of Atrial Fibrillation

Atrial Fibrillation (AF) is the commonest heart rhythm disturbance. It occurs as a result of
unco-ordinated activity within the heart’s upper chambers and results in an irregular heart
rhythm. The lack of proper contraction in the upper chambers results in stagnation of blood
and clot formation which predisposes to stroke. (NHS Improvement, 2010).

Prevalence rates in Primary Care are 1.2% which equate to just over 600,000 patients in
England with AF. These figures are likely to be an underestimation because in many patients
the condition is undetected.

The prevalence data shows that AF increases with each decade of age. As a consequence,
detection and appropriate management of AF is of particular importance in the elderly.
Prevalence rates may continue to rise in the future due an ageing population and increased
survival rates for conditions associated with AF.

The percentage of strokes attributable to AF has been estimated as:

       1.5% for patients in their fifties
       2.8% for patients in their sixties
       18.8% for patients in their seventies
       23.9% for patients in their eighties

Therefore the importance of recognising and treating AF increases with age.

This scheme aims to improve the identification and management of patients AF within
primary care.

AF is both under recognised and under treated and evidence demonstrates that systematic
screening increases the detection of new cases by approximately 60%. It is known that:

       AF is an important risk factor for stroke and is associated with about 15% - 20% of all
        strokes
       It has been estimated that optimal treatment of AF in the population would reduce
        overall stroke risk by 10%
       Anticoagulation is highly effective in reducing stroke risk in patients with AF by
        approximately 70%
       In a primary care population of about half a million, there will be approx 1000 new
        cases of stroke per annum.




Triple Aim Programme of Work 2011/12                                                   Page 14
There are a small number of validated schemes for stratifying stroke risk in AF and
identifying those patients at high risk of stroke. The GRASP – AF tool has been developed to
search / interrogate practice systems to look at current AF management for best evidence
based care. It is known from national information that Warfarin is under prescribed in
patients known to be at high risk. This tool will enable us to look at the AF register and
ensure appropriate management of these patients.



Project                                          Payment
Pulse checks to detect irregular pulse on        £2 per pulse check
patients >65 years

Attendance at Education event                    £200 per practice

GRASP tool to evaluate AF register               £200 per practice



The audit requirements will be taken from the quarterly Triple Aim data submission.




Triple Aim Programme of Work 2011/12                                                    Page 15
Early Identification of Alcohol Misuse

Bolton is, along with several other parts of the North West, well above the national average
for the prevalence of problem drinking. The North West Public Health Observatory’s Local
Alcohol Profile suggests that Bolton is in the top quarter nationally for all measures of
alcohol related impact on health.

Within Bolton it is currently estimated following the Bolton Health Survey 2007, that there
are approximately 38,000 hazardous drinkers and 21,000 harmful drinkers of whom 10,000
are very heavy or dependent drinkers as defined by the CAGE questionnaire. These figures
are likely to be under estimates because of the problem of under reporting.

The overall aim of the scheme is to raise awareness in the practice population of the
damage alcohol can have on health. It includes the identification of patients whose alcohol
consumption is hazardous or harmful; the provision of educational interventions and
support in behavioural change and referral to specialist services as appropriate.

This industrially scaled scheme aims to target all patients aged 16+ to undertake an AUDIT
C questionnaire.

Any patients achieving a score equal to or greater than 5 points can then be referred to the
Health Trainer for a full assessment as per attached pathway.



Project                                        Payment
AUDIT C Questionnaires completed on            £2 per AUDIT C completed
patients >16 years



The audit requirements will be taken from the quarterly Triple Aim data submission.




Triple Aim Programme of Work 2011/12                                                  Page 16
  Triple Aim in Primary
           Care



                              Alcohol LES - Primary Care Pathway

                                          AUDIT C                                                          Patient refuses
               (Alcohol Use Disorders Identification Test)                                                     Audit C

                             This patient audit can be                                                           Code –
                          undertaken by any practice staff                                                  (Audit C refused)
               e.g. GPs, nurses, health care assistants, receptionists




    Patient agrees to Audit C and scores                              Patient agrees to Audit C and scores 5
                 4 or below                                                           or more

              Code – 9K17 or XaMwb                                               Code – 9K17 or XaMwb
                  Audit C completed                                                  Audit C completed
              Add score to comments box                                          Add score to comments box

   Provide patient information leaflet on safe drinking                   Refer to Health Trainer for Audit 10

                                                                       Referral accepted Code – 8HIF or XaQAA
                                                                         Referral declined – 81AL or XaQAN
                                                                                     Audit C completed
                                                                                 Add score to comments box
                   Patient refuses Audit 10
                                                                      Provide patient information leaflet on safe drinking
                                Code –
                            (Audit 10 refused)




                                                 Patient undertakes Audit 10

                                                    Code – 9K15 or XaMwZ
                                                      (Audit Test Completed)
                                                    Add score to comments box




    Patient scores                        Patient scores                 Patient scores                    Patient scores
      7 or below                               8 - 15                        16 - 19                        20 or above

  Patient considered to               Patient considered to           Patient considered to               Patient should be
      be drinking at                      be drinking at                  be drinking at                  offered a referral
       ‘Low Risk’                       ‘Increasing Risk’                  ‘High Risk’                         to ADS

                                            Offer patient               Offer patient “Brief
      Provide patient
                                            “Brief Advice”            Advice” and arrange for
   information leaflet on
                                               (30 min                up to 3 further sessions
        safe drinking
Triple Aim Programme of Work 2011/12                                                                   Page 17
                                      Code – 9k1A or XaPPv                     Code –                  Code – 8HkG or XaORR
  Code – 9k1A or XaPPv
                                       (Brief intervention for         (Brief intervention for          (Referral to specialist
   (Brief intervention for
     excessive alcohol                   excessive alcohol               excessive alcohol                alcohol treatment
                                           consumption)                    consumption)                       services)
Best Care Projects

There are an estimated 295,000 people in Bolton that are registered with GP practices. Of
these the following numbers are on the following disease registers (December 2010).


      10,526 on CHD register
      15,562 on diabetes register
      5,980 on COPD register
      1,839 on Heart Failure register
      3,447 on Atrial Fibrillation register
      12,746 on Chronic Kidney Disease register

The Best Care projects are to improve the quality of care delivered to these patients.

A range of indicators (five indicators for each disease register) have been identified within
these chronic disease registers which will be monitored as part of this enhanced scheme.
Through MIQUEST searches that will be supported through the Triple Aim Data Co-
ordinator, the registers can be interrogated to identify how many patients achieve the 5
identified Best Care indicators.

This Best Care project has been running for 1 year for Diabetes, CHD and COPD registers and
this scheme aims to further embed and monitor these existing schemes whilst extending
into other disease areas (Heart Failure, AF and CKD).

The table below shows baseline points:
  Disease        CHD       Diabetes       COPD        Heart        AF         CKD
   Area                                              Failure

Points                                                TBC         TBC         TBC
achieved

Payments will be made based on the final outcome points for each disease area.

The payments relate to the number of patients on the disease register

Project                                         Payment
Best Care Achievement score                     Average payment for 400 point AQUA
(see attached scoring charts)                   achievement:
                                                CHD - £3
                                                Diabetes - £3
                                                CKD - £3
                                                COPD - £3
                                                AF - £9
                                                Heart Failure - £9
Information will be collected quarterly through MIQUEST searches by the Triple Aim data
co-ordinator



Triple Aim Programme of Work 2011/12                                                     Page 18
                                           Triple Aim in Primary Care
                                           BEST CARE INDICATORS (2011-12)



                                                  Atrial
      CHD               Heart Failure          Fibrillation          CKD            Diabetes             COPD
   1. Non-              1. Non-smoking         1. Non- smoking   1. Non-smoking     1. Non-          1. Non-smoking
      smoking                                                                          smoking
                                                                 2. ACR recorded                     2. % Predicted
   2. BP less           2. Ace Inhibitor       2. Pulse rate        (Code 46TC,     2. BP less          Fev1 (Code
      than or                                     checked           X773Y or           than or          339S or XaEFz)
      equal to                                    (Code 242..,      XE2n3)             equal to
      150/90                                      X773s)                               145/85

   3. Cholesterol       3. Pulse Rhythm        3. CHADS2 Risk    3. Annual eGFR     3. Cholester     3. COPD
      less than or         (Code 2431,            score             (Code 451E or      ol less          Management
      equal to 5.0         2432 Or 2433,          (Code 38DE        XaK8y)             than or          Plan (Code 66YI
                           XE1hK%,                or XaP9J)                            equal to         or XaIUt)
                           Xa7sd%)                                                     5.0
   4. Beta-             4. Beta-blocker        4. Anti-          4. BP to target    4. Hba1c         4. Inhaler
      Blocker                                     coagulation                          less than        technique good
                                                                                       or equal to      (Code 663H)
                                                                                       7.0           5. Depression
   5. Anti-platelet     5. Management          5. Management     5. With/out                            Screening
                           Plan*                  Plan*             proteinuria     5. ACR              (Code 6896 or
                           (Code 8HBE or          (Code 6A9 or                         recorded         XaLIc)
                           XaIQN)                 XaMGD)                               (Code
                                                                                       46TC,
                                                                                       X773Y or
                                                                                       XE2n3)

Triple Aim Programme of Work 2011/12                                                                         Page 19
CHD/COPD/Diabetes/CKD scoring chart

                                                        Triple Aim in Primary Care
                                         Marmotised Scoring Chart - CHD/ COPD/ CKD & Diabetes
    £4.00
                                              Fuschia                 Aqua               Beige

    £3.50


    £3.00


    £2.50


    £2.00


    £1.50


    £1.00


    £0.50


    £0.00
            200   220    240      260   280   300        320    340          360   380    400    420   440   460       480




Triple Aim Programme of Work 2011/12                                                                               Page 20
AF/HF scoring chart

                                        Triple Aim in Primary Care
                                        Marmotised Scoring Chart- HF/AF
  £12.00
                                             Fuschia               Aqua               Beige


  £10.00



   £8.00



   £6.00



   £4.00



   £2.00



   £0.00
           200   220     240     260   280   300       320   340          360   380    400    420   440   460        480




Triple Aim Programme of Work 2011/12                                                                            Page 21
Triple Aim Programme of Work 2011/12   Page 22
Improving Ethnicity Recording
The Equality Act 2010 introduces new specific duties that require pubic sector bodies to identify
gaps in data that it collects by equality group, in relation to its services and functions, and to take
action to improve the quality of this data.

The aim of collecting such data would be to extend the good work the PCT has done to date on
understanding local demographic inequalities, so that a more detailed picture on inequalities that
exist within communities based on equality characteristics (for example ethnicity or disability), can
be developed and understood.

A key gap in data available is that which relates to health outcomes by ethnic group.

We know, from national data for example, that Pakistani men aged over 55 are twice as likely to
suffer from CHD and are 50% more likely to have CVD.1 However, due to the lack of data, we do not
understand if this picture is reflected locally, and would also be unable to measure any
improvements if targeted action was taken to address this.

The project proposal below aims to improve the ethnicity data we have against patients on two key
disease registers (diabetes and CHD), to allow us to analyse for inequalities in health outcomes or
risk factors by ethnicity group and to build this into wider Triple Aim work around Better Health.

Through the Triple Aim in Primary Care Programme the following are suggested:

       1. To request, on a quarterly basis, how many patients aged 16+ within each practice has
          ethnicity status recorded. Each practice will be issued with the standard ethnicity groups.
          This data will be requested through the already established data collection audit proforma
          from each practice

       2. There will be a one off incentivised project adding in ethnicity groups to specific registers i.e.
          diabetes and CHD registers. The ethnicity will also be included within the Best Care projects
          for these disease areas so that we can monitor outcomes and Best Care achievements
          between ethnic groups. We would encourage the recording of ethnicity on these disease
          registers. We know there are currently 10.526 patients on the CHD register and 15,562
          patients on the diabetes register (Dec 2010).

Project                                                          Payment
Recording ethnicity on all patients on CHD                       £1 per patient on these registers
and Diabetes registers



The information will be collected through a MIQUEST search at the same time as the best
care information is collected.



1
    British Heart Foundation – Ethnic Differences in CVD. 2010


Triple Aim Programme of Work 2011/12                                                                 Page 23
Supported Projects

The following projects are also ongoing throughout 2011/12.

      COPD Screening

This project aims to promote early identification and increase prevalence of COPD in Bolton.

Background:

It is estimated that 50% of people with COPD are not aware they have the disease. The
prevalence of COPD in Bolton is 2.0% (Dec 2010) but the predicted prevalence is 4.6%.

The project is targeted at all adults aged 40+ without COPD or asthma. These patients can
then be invited / offered a COPD screening with a FEV6 meter. This device enables the
clinician to determine whether the patient needs to go on to have spirometry.

The Triple Aim team have secured funding for the provision of FEV6 meters. These meters
can be provided to any practice wishing to participate following training.

If practices wish to access this training and obtain an FEV 6 meter they can do so by
contacting Lesley Buxton, Triple Aim Pharmacist on 01204 463185 or by e-mail at
Lesley.buxton@bolton.nhs.uk



      Cancer Information

This project will promote cancer awareness and early diagnosis, focussing on breast, bowel
and lung. There will be a network wide ‘Don’t be a Cancer Chancer’ social marketing
campaign. The social marketing campaign enables a tailored message for a specific
audience, to be targeted and delivered across Greater Manchester. The approach will be to
seek awareness of potential signs and symptoms of cancer and motivate people with
symptoms to go to their GP.

Triple Aim will also include an education event regarding the awareness and early diagnosis
of cancer. Within the Triple Aim information reports there will be a section focussing on
Cancer that can monitor the effects and outcomes of the campaign and education. The
screening rates will also include enabling practices to monitor their achievement against
their peer cluster average.

For more information or to arrange Cancer Awareness Training contact Audrey Howarth on
01204 462147 or by e-mail at Audrey.howarth@bolton.nhs.uk




Triple Aim Programme of Work 2011/12                                                    Page 24
      Maternal and Child Health Information

This project will collect information on indicators specific to maternal and child health.

Within the Triple Aim information reports there will be a section which focuses on Maternal
and Child indicators such as immunisation rates, breast feeding rates and smoking in
pregnancy rates. This will enable practices to monitor their achievement against their peer
cluster average.

For more information contact Nicki Lomax on 01204 462149 or by e-mail at
nicki.lomax@bolton.nhs.uk

      Mental Health

This project will collect information relating to Mental Health, Dementia and Depression
registers. This will enable practices to monitor their achievement against their peer cluster
average.

There will also be a focus on dementia in 2011/12 with an education session specifically
looking at the diagnosis and management of these patients.



Education Programme

There will be an education programme to support the projects within the Triple Aim
Programme of Work.
General principles have been agreed:

      A mix of sessions and timings would be required mainly on Wednesday afternoons. The
       sessions will be delivered at borough level, within localities and also at individual practices
       for those not attending dedicated sessions.
      The sessions will target all staff including clinical staff, both GPs and nurses, practice
       managers and admin staff
      Topics are aligned to Triple Aim Programme of work
      Some topics need to be addressed through Clinical Governance
      The diary allows for 12 x 2hour sessions per year, however there will need to be some
       flexibility within the programme to deliver ‘hot topics’ as they arise.

The programme for 2011/12 is attached. Information regarding these sessions will be sent to
practices as well as posted on Bolton Medical Learning Zone ( http://gp.boltonmlz.co.uk/ )

For more information regarding the education programme please contact Dr Tarek Bakht on 01204
423168 or e-mail tarek.bakht@nhs.net or to book onto education programmes contact Sue Stahler
on 01204 463054 or e-mail sue.stahler@bolton.nhs.uk




Triple Aim Programme of Work 2011/12                                                            Page 25
Education Programme

          Month         Health Outcome Area                Topic                                   Comment
   28th April          CVD                    Primary Prevention           Update on Screening and annual review projects
                                                                           Role of HT
                                                                           Management of patients inc. Medicine Mgt

   25th May            CVD                    Atrial Fibrillation          Best Care LES
                                                                           Screening
                                                                           Management of patients

   22nd June           CVD                    CKD                          Update on staging
                                                                           CVD Risk Management
                                                                           Update from CLAHRC
                                                                           CKD Best Care

   6th July            CVD                    Heart failure                Update on BNP
                                                                           Management of Heart Failure
                                                                           Update on Best care LES

   27th July           Mental Health          Dementia                     Mental Health Triple Aim Data
                                                                           Focus specifically on dementia prevalence
                                                                           NICE guidance for management
                                                                           Care reviews

   August              FLEXI


   28th September      Diabetes               Impaired Glucose Tolerance   Update from CLAHRC
                                                                           Feedback from evaluation
                                                                           Feedback on prevalence data and identification protocol
                                                                           Update Best Care LES


Triple Aim Programme of Work 2011/12                                                                                           Page 26
   26th October        Respiratory               COPD / Asthma       Update on Best Care COPD LES
                                                                     Update on Case finding
                                                                     Update on Inhaler project
                                                                     Encourage the use of self management plans and flu uptake
                                                                     in lieu of winter

   23rd November       Alcohol                   Alcohol             Epidemiology of alcohol
                                                                     Audit c
                                                                     NICE Guidance
                                                                     Hospital perspective

   December            FLEXI


   25th January        Cancer                    Cancer              Update on screening rates
                                                                     Update on information from Cancer Network
                                                                     NAEDI Bids

   February            TBA

   March               TBA

   Other (Clinical     Maternal & Child Health   Key Messages        DNA/ Missed appointments
   Governance)                                                       Feeding information
                                                                     Child health surveillance
                                                                     Unseen child policy

   Other (Clinical     Diabetes                  HbA1c measurement   HbA1c measurement
   Governance)                                                       NICE Guidance




Triple Aim Programme of Work 2011/12                                                                                    Page 27
Triple Aim Programme 2011/12 Sign Up form

                    Triple Aim Programme 2011/12 Sign Up Form
Practice:


Practice Manager:


Contact Details:


                            Project                         Sign up – please tick all
                                                                  that apply
Provision of Triple Aim data

Primary Prevention Screening (BBHC)

Primary Prevention Annual review

Early Identification of Impaired Glucose Tolerance /
Diabetes

Early Identification of Atrial Fibrillation

Early Identification of Alcohol Misuse

Best Care Projects:                                        1.
   1. Coronary Heart Disease                               2.
   2. Diabetes                                             3.
   3. COPD                                                 4.
   4. Atrial Fibrillation
                                                           5.
   5. Heart Failure
                                                           6.
   6. Chronic Kidney Disease
Improving Ethnicity recording on CHD/Diabetes registers

COPD Screening Project

Please return this form to Lynda Helsby, Triple Aim Programme Manager at
lynda.helsby@bolton.nhs.uk




Triple Aim Programme of Work 2011/12                                          Page 28

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:8
posted:10/16/2011
language:English
pages:28