20,000 Days Campaign Storyboard Learning Session 3 11-12 March 2013 Healthy Hearts

Collaborative Team Clinical Lead: Key Contacts: Project Manager: Clinical collaborative co-ordinator: Improvement Advisor: Decision Support: Dr Mayanna Lund Andy McLachlan Dr Andrew Kerr June Poole Katherine McLean Dr Tim Sutton Leanne Elder Sitela Vimahi Sosefo Teu Devi Ann Hall Alison Howitt Sarah Mooney Ian Hutchby Tanesha Patel & Eric Cuvea

Aim To improve cardiovascular health in the CMDHB population, across the continuum of care, by July 2013 by: Reducing readmission rates from Congestive Heart Failure by 20% And increasing the uptake of cardiac rehabilitation rates by 10% And Improve access to inpatient Echo and catheter testing so that 70% appropriate referrals are seen within clinically agreed timeframes

Change Packages – Heart Failure Pathway

Appropriate & tailored care Change Packages 2o Drivers (Theory of change) Change Ideas Tested Describe Process Early Diagnosis Using lab test taken in ED Review BNP results for Early Identification of new Heart Failure Patients Hand Held Echo Use Hand Held Echo to confirm underlying heart disease, enabling treatment plan to be initiated early. Appropriate & tailored care Multi-disciplinary wards rounds. Includes, Cardiologist (with Hand Held Echo) and Nursing team to initiate integrated care package.

Change Packages 2o Drivers Change Ideas Tested Describe Process (Theory of change) Change Ideas Tested Describe Process Consistency of Care Heart Failure Care Bundle Heart Failure Diagnosis Patient information and Education (taking Control) Medicine management Self Management Plan Cultural Support Patient understanding (language) Patient information and Education Reduced barriers to self-management Post Discharge Follow Up Phone call to support patient and identify problems early

Change Packages 2o Drivers Change Ideas Tested Describe Process (Theory of change) Change Ideas Tested Describe Process Titration Clinics Nurse led titration clinics to increase capacity. Heart Failure Rehabilitation Provide Patient Information, Education and Exercise to support patient self management. Combined HH & BB Rehabilitation Use community based resources to develop programmes.

Healthy Hearts CNS Dashboard Version 1 – 10th March 2013

Patient journey EARLY DIAGNOSIS INPATIENT STAY OUTPATIENT SUPPORT BNP / HHE INPATIENT STAY Education & cultural support OUTPATIENT SUPPORT Telephone follow-up Titration clinics GROUP & COMMUNITY SUPPORT Shared exercise/education programme

Patient story: 66 year old female on W2 EARLY DIAGNOSIS BNP 68 (requested 12.17 / results viewed/accepted 13.37) Echo undertaken Diagnosis confirmed Medication commenced BNP / HHE INPATIENT STAY Education received on two occasions from nurse specialist Pharmacy review of medication Noted that English second language or poor English comprehension Education & cultural support OUTPATIENT SUPPORT Telephone follow up Letter to GP/on Concerto noted: “xx is still feeling breathless at times during the day and is waking at night with shortness of breath”. I have asked xx to see you tomorrow for review”. “xx has limited knowledge of her medications even though these were discussed during her hospital stay. She would benefit from going over her medications again”. “Referrals made: Heart failure nurse practitioner on xx. Please could you encourage her to attend”. Nurse practitioner clinic Telephone follow-up Titration clinics GROUP & COMMUNITY SUPPORT Opportunity to attend with family member: Personalised and supervised exercise prescription Education sessions including on medication Meet and monitor weekly with nurse/physio Shared exercise/education programme

Patient journey EARLY DIAGNOSIS INPATIENT STAY OUTPATIENT SUPPORT BNP / HHE INPATIENT STAY Education & cultural support OUTPATIENT SUPPORT Telephone follow-up Titration clinics GROUP & COMMUNITY SUPPORT Shared exercise/education programme PDSA tree PDSA tree Run charts

Most Successful PDSA Cycles?

Measures Summary Dashboard (Re-admissions, Admissions and LoS) Interventions Numbers hand held echo’s and outcomes Management plans completed Follow up phone calls completed Patient completing titration clinic Specialist clinics – patient numbers Identification of patients with heart events Numbers of patients attending/completing Rehab Wait times for cardiac diagnostics Non Coronary Care pts with positive biomarker

20,000 Days Healthy Hearts Dashboard January 2013 Monthly volumes for Chronic Heart Failure patients are unstable and shows some element of seasonality ALOS for Chronic Heart Failure patients is predominantly showing normal variation The Readmission rate for CHF patients is stable and exhibits normal variation only 20,000 Days Healthy Hearts Dashboard January 2013 Since mid-November the number of successful calls per week has increased Monthly volumes for ACS patients are stable and exhibit normal variation only Average Length Of Stay for ACS patients is stable and exhibits normal variation only The Readmission rate for ACS patients is stable and exhibits normal variation only Version: 1.1 Dated: 11/02/2013 Contacts Improvement Advisor: Ian Hutchby Decision Support Analyst: Tanesha Patel/Eric Cuerva

Achievements to date Team building / shared & and agreed focus on patient journey/outcome Evidence collection Fitting the jigsaw pieces into a coherent and appropriate Heart Failure Pathway Efficient, empowering and co-ordinated care Patient journey