Project Name: Darlington Community Lipid Clinic – Collaborative Working Project

Project Summary:

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

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

The CWP will be led by a General Practitioner with Extended Role alongside a multi-disciplinary team; including Pharmacy Technician and Healthcare Assistant aiming to achieve:

  1. Identification of sub-optimally treated patients who are not achieving recommended targets for lipid management 
  2. Identification of patients who have previously not tolerated or refused alternative lipid modification therapies 
  3. Review of treatment options and decision on next steps in collaboration with patients 
  4. Counsel and optimise patients where appropriate 
  5. Early identification of at-risk patients who have not had intervention in their health and wellbeing
  6. Identification of patients, following risk assessment review, of patients who are suboptimally treated  
  7. Re-patriation to all 11 practices through patient care plan letters and audit pro-forma to create sustainable change within the PCN.

Planned Milestones:

  1. Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table
  2. Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin the clinical activity
  3. Confirmation of recruitment of Pharmacy Technician
  4. Collection of 3 months clinical activity data & Project Review meeting to discuss project progress. 
  5. Collection of 6 months clinical activity data & Project Review meeting to discuss project progress. 
  6. Collection of 9 months clinical activity data & Project Review meeting to discuss project progress. 
  7. Collection of 12 months clinical activity data & Project Review meeting to discuss project progress. 
  8. Collection of 15 months clinical activity data & Project Review meeting to discuss project progress. 
  9. Collection of 18 months clinical activity data & Project Review meeting to discuss project progress. 
  10. Collection of 21 months clinical activity data & Project Review meeting to discuss project progress. 
  11. Collection of 24 months clinical activity data & Project Review meeting to discuss project progress. 
  12. Development of business case
  13. Analysis of CWP data, submission of Final CWP Report, Submission of Outcomes Summary  

Expected Benefits:

Anticipated benefits for patients:

  • Improved access to lipid management care leading to optimal diagnosis and management of ASCVD treatments.  
  • Enhanced experience around ASCVD with ongoing management of the condition.  
  • Improved access to appropriate medication for suitable patients to preserve health and prevent long-term events 
  • Easier access to lipid management care closer to home in the Primary Care setting
  • The additional capacity will provide additional time and support from PCN HCP with their lipid management, focusing on patients who may have previously not attended GP appointment or been lost to follow-up. Thus, leveling health inequalities within the PCN. 
  • By identifying high risk patients with CVD and hypercholesterolaemia and those with known and undiagnosed familial hypercholesterolaemia and offering education, lifestyle advice, holistic assessment and appropriate lipid lowering therapy including intensification to achieve evidence based and guideline recommended targets, the project aims to achieve a reduction in incidence of cardiovascular events including stroke, TIA and acute coronary syndromes and ischaemic heart disease in these individuals.

Anticipated benefits for partner organisation:

  • Increased proportion of ASCVD patients reviewed by primary care  
  • Increased proportion of ASCVD patients receiving expert and timely review closer to home 
  • Reduction in ASCVD referral rates to secondary care and thus reducing pressure on secondary care services
  • Increased proportion of patients receiving guideline-directed pharmacotherapy 
  • Insight into benefits of primary care pharmacist led lipid management clinics in primary care  
  • Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES
  • Re-patriation to all 11 practices through patient care plan letters and audit pro-forma to create sustainable change within the PCN.
  • Running an additional service in primary care/community will ease waiting list pressures on secondary care lipid clinics and pilot a new way of working

Anticipated benefits for Novartis:

  • Insight on the appropriate use of ASCVD licensed medicines in line with NICE guidelines, including Novartis’s medicine 
  • Enhanced reputation, and supporting Novartis’ vision that no patient should have to wait for an extraordinary life, by supporting high quality Collaborative Working with healthcare organisations which addresses the problem of health inequalities   
  • Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisation 

Start Date & Duration: September 2022 – 27 months

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Project Name: Darlington Community Lipid Clinic – Collaborative Working Project

Completion Date: July 2023

Outcome Summary:

The project achieved the establishment and implementation of a Community Lipid Clinic in Darlington PCN. The Community Lipid Clinic conducted 3 months of clinical activity, identifying, reviewing, and optimizing ASCVD patients, however, the Parties have decided to close the project prior to the expected end date of the project due to extenuating circumstances.

Key Project Outcomes Data:

580 patients identified for review in the Community Lipid Clinic.

32 patients attended a lipid review clinic as part of the service provided by this project.

Outcomes:

Milestones 1, 2, & 4 of this project have been completed. The Parties have decided to close the project due to extenuating circumstances.

Milestone 1 completed: Collection of baseline data.

Milestone 2 completed: Creation and implementation of clinical and operational lipid management pathway, policy, and protocol.

Milestone 3 completed: confirmation of recruitment of additional clinical resource.

Milestone 4 completed: collection and submission of 3 months clinical activity data.

Conclusion:

Prior to early closure of the project, the project was achieving the objective of the CWP is to improve the quality of care for patients and support the early identification, review, and medical optimization of patients with atherosclerotic cardiovascular disease (ASCVD) in response to the needs of the CW Partner.

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