Project Name: Lime Tree Surgery ASCVD Primary Care Lipid Management Collaborative Working Project
Project Summary:
The Cardiovascular Wellness Program (CWP) aims to enhance patient care and improve outcomes for individuals with atherosclerotic cardiovascular disease (ASCVD). It follows the guidelines set by the Primary Care Network (PCN) Contract Direct Enhanced Service (DES) and the local cardiovascular plans.
A previous collaboration focused on specific cohorts of patients and was completed over 12 months before the start of this project. This collaboration is different as it aims to expand the cohorts to optimise treatment for patients who are not at target cholesterol levels despite being on a lipid lowering therapy (some of which were identified during our previous collaboration).
The CWP is designed to be a multidisciplinary effort, led by a Pharmacy Technician, and supported by a team consisting of a Clinical Pharmacist, Nurse (Band 7), General Practitioner, Healthcare Assistant, and Nurse Associate.
The program aims to achieve the following objectives:
- Identify ASCVD patients who are at high risk of cardiovascular events and are not achieving recommended lipid levels according to national and/or local guidelines.
- Identify ASCVD patients who are at higher risk of cardiovascular events and have previously not tolerated or refused alternative lipid modification therapies.
- Review treatment options for ASCVD patients and make collaborative decisions on the next steps.
- Provide counselling and optimize management for ASCVD patients when appropriate.
- Early identification of at-risk patients who have not received appropriate health interventions.
- Identify ASCVD patients who are not optimally treated after conducting a risk assessment review.
- Provide ongoing support and conduct annual reviews for ASCVD patients to ensure equitable improvement in cardiovascular outcomes.
Planned Milestones:
| Milestone description | Milestone delivery date | |
|---|---|---|
| 1 | CW Partner: Collection of baseline data, in line with the above Project Outcome Measures & Data Collection table. | Within 1 month of execution of the CWA |
| 2 | CW Partner: Confirmation of clinical and operational pathway, policy and protocol creation, and readiness to begin | Within 1 month of execution of the CWA |
| 3 | CW Partner: Confirmation that the clinical activity has started. | Within 1 month of execution of the CWA |
| 4 | CW Partner: Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary CW Partner & Novartis: Project Review meeting to discuss project progress. | Within 3 months of execution of the CWA |
| 5 | CW Partner: Development of business case to continue the service offered by this project. | Within 7 months of execution of the CWA |
| 6 | CW Partner: Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary . | Within 9 months of execution of the CWA |
Expected Benefits:
Benefits for Patients
- Improved access to optimal ASCVD diagnosis and management through enhanced lipid management care.
- Enhanced patient experience with ongoing management of ASCVD. Increased access to appropriate medication for eligible patients, promoting health preservation and preventing long-term events. Convenient access to lipid management care in the Primary Care setting, closer to home.
- Additional capacity allowing for more time and support from Surgery HCP for lipid management.
Benefits for patients
- Higher proportion of ASCVD patients receiving primary care reviews.
- Reduction in health inequalities within the surgery as the project targets patients who may not have previously attended GP appointments or who have been lost to follow up.
- Improved access to expert and timely reviews for ASCVD patients closer to home.
- Reduction in referrals of ASCVD patients to secondary care.
- Increased proportion of patients receiving guideline-directed pharmacotherapy. Enhanced understanding of the benefits of primary care pharmacist-led lipid management clinics. Support that aligns with the NHS Long Term Plan, CVDPREVENT, and Network Contract DES.
Benefits for Novartis
- Insight on the use of ASCVD licensed medicines in line with NICE guidelines, including Novartis’s medicines, where appropriate.
- 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:
Proposed start date: 1st March 2025
Total Project: Nine Months
Clinical Activity: Six Months commencing after one month.
FA-11375438