Project Name: ASCVD and Lipid GP-led Primary Care Model of Care – Collaborative Working Project
Organisation(s): FEDERATION OF FAMILY PRACTICES OF MID ULSTER Community Interest Company (C.I.C)., Company number NI639091, of Unit 129 The Courtyard Galgorm Ca, Galgorm Road, Ballymena Antrim BT42 1HL
Project Summary:
The 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) who are at high risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidance, in response to the needs of the CW Partner.
- Identification of sub-optimally treated ASCVD patients who are at high risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidelines
- Identification of ASCVD patients who are at higher risk of cardiovascular events and who have previously not tolerated or refused alternative lipid modification therapies
- Review of treatment options and decision on next steps in collaboration with ASCVD patients
- Counsel and optimize ASCVD patients where appropriate
- Early identification of at-risk patients who have not had intervention in their health and wellbeing
- Identification of ASCVD patients, following risk assessment review, of ASCVD patients who are sub-optimally treated
- On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably
- Education, support, and standardisation of Healthcare Professional (“HCPs”) with regards to ASCVD
Planned Milestones:
| Planned Milestones | |
|---|---|
| 1 | Lipid Management pathway/protocol development |
| 2 | Collection of baseline data, in line with the Project Outcome Measures & Data Collection table |
| 3 | Clinical audit and clinical audit discussion with member practices. |
| 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 | Development of business case |
| 8 | 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 and counselling 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 for lipid management, focusing of patients who may have previously not attended GP appointments or been lost to follow-up. This help to level health inequalities within the practice and, ultimately, in a wider setting.
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
- Increased proportion of patients receiving guideline-directed pharmacotherapy
- Insight into benefits of novel primary care led lipid management clinics and demonstration of benefit via development of business case for substantive funding
- Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES
- Opportunity to show the impact of the CWP to create lasting change in lipid management within the Kingswinford and Wordsley PCN
Anticipated benefits for Novartis:
- 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
- Increased proportion of patients receiving guideline-directed pharmacotherapy
- Insight into benefits of novel primary care led lipid management clinics and demonstration of benefit via development of business case for substantive funding
- Support aligned to NHS Long Term Plan, CVDPREVENT, and Network Contract DES
- Opportunity to show the impact of the CWP to create lasting change in lipid management within the Kingswinford and Wordsley PCN
Start Date & Duration: June 2024 – 12 months
UK2406181359