26 th February 2015

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd" Patient Diagnostic and education Most appropriate healthcare professional Improved Outcomes  The Apodi Integrated Care Clinics are designed to ensure that all necessary components of delivering care are available at the point of patient presentation.  Apodi Healthcare is CQC registered and complies with all regulations for patient safety and data protection.

ItemPoints Chronic Heart Failure1 Hypertension1 Age Age >752 Diabetes1 Previous stroke or TIA or thromboembolism2 Female sex1 Total9 Patients identified through GRASP AF with CHA 2 DS 2 -Vasc score of >1 or more invited to SPAF ICC "This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd"

 Patient led discussion group with specialist nurse- 30 minutes Provide further access to additional services Patient questionnaire- confirmed need for further ongoing support in the community  Individual nurse led triage- Anticoagulation, BP, Pulse check, Risk Assessment- CHADS 2 & HASBLED  Where appropriate clinical review by doctor  Only recommendations on the day- GPs retain control of patients. All clinicians are independent.

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd" Practice report provided following clinic- attendance, recommendations and feedback

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd" Clearly presented with time to ask questions Great care taken by the doctor to explain my condition Reassurance my condition is being treated correctly The good thing about this experience was that I was given information about my diagnosis that I wasn't told before. The doctor informed me of my options and allowed me to make my ow n decision about medication. Gave me peace of mind. Enjoyed the experience. Staff very helpful and friendly

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd" The nurses are of very high quality and a pleasure to work with, patient feedback to me was fantastic Dr Watts – Belmont Surgery 12/12/2014 Well organised. Excellent nurse. BP, pulse, CHA 2 DS 2 VASC all done. Patients loved it Dr Dua – Weobley Surgery 5/4/2014

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd"  Patients attending the SPAF ICC – current management and recommendations for management post ICC

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd"

Provide access to a range of tools Provide pre-written MIQUEST query libraries Provide primary care data expertise and advice PRIMIS…

What is GRASP AF?  Guidance on Risk Assessment and Stroke Prevention for Atrial Fibrillation  Initially developed by the West Yorkshire Cardiac Network  NHS IQ National Priority Projects  Suite now includes COPD and Heart Failure audits

GRASP AF case finder  Have we missed any people with known AF off our register because we haven’t added a morbidity code?  Are there any people with suspected (but not confirmed) AF in the past who might need review for possible inclusion in the register and treatment?

GRASP AF  Identifies patients who have been coded with AF or atrial flutter  Stratifies patients for stroke risk (CHADS 2 and CHADS 2 VASC)  Assesses anti-coagulant therapy and contra- indications  Provides a summary of practice results and patient level detail for case review

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd"  AF registers before & after clinics  Number of high risk patients not on anticoagulant before & after clinics  Data from 10 practices so far (of 23)

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd"  AF registers before & after clinics   Number of high risk patients not on anticoagulant before & after clinics   4.2 strokes prevented

Accessing PRIMIS+ resources  Quick Profile Centre registration to access:  – CHART Software – Pre-written Query Sets – MIQUEST Instructions – CHART Online  Opt in to receive updates from PRIMIS+  Participate in the PRIMIS+ Discussion Board  Contact your local Facilitator for direct support

Herefordshire AF Pathway

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd" Healthcare

"This SPAF Integrated Care Clinic Programme is funded by Bayer HealthCare as a service to medicine and delivered by Apodi Ltd" Jacinta Meighan-Davies:Clinical Programme Manager HCCG Dr Ritesh Dua : Urgent Care GP lead HCCG Dr Dave Jeffery : Primary Care Data Quality Lead Penny Hayward – NHS Strategic Programme Manager