1. 1 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 QUALITY IMPROVEMENT IN PRIMARY CARE A Care bundle approach Slide Set 2 (rev Sept2014)

2. 2 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Content Rationale for quality improvement (QI) in kidney disease The QI approach – the care bundle for CKD Methods of implementation Practical issues Methods of evaluation Slide Set 2 (rev Sept2014)

3. 3 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Have evidence-based guidance (NICE 2014) for managing CKD in primary care but evidence of inconsistency of care -Variation in prevalence recording (www.ic.nhs.uk) -Difficulties with proteinuria measurement -Blood pressure QoF vs NICE targets Variability of care Rationale: variability in care Slide Set 2 (rev Sept2014)

4. 4 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Slide Set 2 (rev Sept2014)

5. 5 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Use a care bundle approach “A care bundle is a grouping of several evidence-based elements carried out at the same time, that have the potential to significantly improve patient care outcomes” -Use evidence based guidelines -Include patients in design of the approach -Reduce inconsistency – aim to achieve 95% reliability Develop innovative ways to improve consistency Slide Set 2 (rev Sept2014)

6. 6 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Anticipated impact Aim to achieve 95% compliance with bundle - only if all components are applied at the same time Secondary outcomes: - Accurate CKD register - Improved proteinuria testing - Improved BP control - Reduced cardio-vascular risk Slide Set 2 (rev Sept2014)

7. 7 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 A care bundle for CKD ( rev Sept2014 ) A.Ask the person whether they want to take part in self-management B.Measure and document proteinuria and prescribe appropriate medication (ACE/ARB) if proteinuria present C.Document blood pressure and treat if above NICE (2014) targets D. Offer A torvastatin for primary or secondary prevention of CVD to people with CKD ( ref NICE CG181 )* *Following NICE Lipid modification guidelines 2014, this replaces previous care bundle component Slide Set 2 (rev Sept2014)

8. 8 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Self-management activities 1.Information booklet 2. Encourage self-management 3. Group education session Slide Set 2 (rev Sept2014)

9. 9 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 PLAN Collect baseline data Identify start date and method DO Start intervention STUDY (every month) Examine data - reliability of bundle ACT Make changes Slide Set 2 (rev Sept2014)

10. 10 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Ask whether the person wants to take part in self-management activities Measure and document proteinuria and prescribe appropriate medication (ACE/ARB) if proteinuria present Document blood pressure and treat if above NICE (2014) targets Offer Atorvastatin for primary or secondary prevention of CVD Explain what is required and give out Information booklet Check if ACR done within last 15 months » If yes and positive, then check if on ACE/ARB and document » If no, then ask to provide sample and document » Take BP and document » If above target then treat to target and document Outline of activities (see care bundle documentation) Slide Set 2 (rev Sept2014)

11. 11 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Implementation Identify lead clinician plus one/two other people to assist (usually best if GP, practice nurse and practice manager/IT manager is involved) Identify one clinic in which the care bundle can be started Identify start date ‘Walk-through’ process before start Slide Set 2 (rev Sept2014)

12. 12 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Practical issues Whether to use paper or electronic care bundle sheets Where to keep new and completed care bundle sheets Where to keep Information booklets Who will be in charge of collating monthly data Who will act as leader and organise discussions on tests of change Slide Set 2 (rev Sept2014)

13. 13 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Learning from other Practices 26 GP Practices in England and Wales participated in the ENABLE-CKD project Over 1300 patients had care bundle applied and over 900 (70%) agreed to self- management All Practices achieved >95% reliability by the end of the project * The 2014 NICE guidance on CV risk was not tested in our study, but the new guidance for Atorvastatin could be included in a Care Bundle Slide Set 2 (rev Sept2014)

14. 14 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Case study 1:Improvements in reliability Practice in SW London (Wandsworth PCT) 8104 registered patients Slide Set 2 (rev Sept2014)

15. 15 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Problem: not achieving high rates of proteinuria measurement Requested urine test (ACR) = early morning urine After discussion urine test = spot urine (any time of day) Led to increased reliability Example of test of change Slide Set 2 (rev Sept2014)

16. 16 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Date of data collection (2011/12)NovDecJanFebMar Observed prevalence of Stage 3 to 5 CKD5% 6% Percentage with proteinuria test in previous 15/1267%70%68%73%79% BP <140mmHg (no diabetes)38%54%70%63%64% BP <130mmHg (with diabetes)12%29%39%42%40% Practice in North Wales (Wrexham) 4294 registered patients Case study 2: Improvements in clinical care Slide Set 2 (rev Sept2014)

17. 17 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 Feedback on self-management materials "I've been to the surgery more this year because of this (CKD) than the rest of the time put together." "I was able to look at the DVD, jot down questions and then get answers - you forget everything because it is such a shock." "She (the practice nurse) has given me the confidence.... and I do feel better now and I have every faith in my nurse." “A positive way in which to improve my health...(the Booklet)." "I have lost one stone since January, if I had not known about this (CKD), I would not have done it." “The Booklet was very helpful, I read it quite often." "The DVD was quite helpful, describing the different stages that people had. I did not want to go any lower than that (eGFR) as I did not want to go on tablets - it was a kick start to helping myself. " Slide Set 2 (rev Sept2014)

18. 18 Project supported by A Package of Innovation for Managing kidney disease in primary care Registered Office: Nene Hall, Lynch Wood Park, Peterborough PE2 6FZ. Kidney Research UK is a limited company registered in England. Registered Company No. 905963 Registered Charity No. 252892. Registered Scottish Charity No. SC039245 A significant number of Practices have continued to use the care bundle approach now the project has ended, having found that despite initial concerns, it could be applied within normal consultation time once they were used to the process All Practices said they were now more aware of CKD and its management, including: – Finding more patients with CKD – Monitoring eGFR and blood pressure – Informing more patients of their diagnosis of CKD All practitioners felt the resources for patients were very useful and added to their knowledge and understanding, as well as helping them to self-manage Practice staff reported that patients were more informed, more involved and grateful for the opportunity Overall evaluation from practitioners Slide Set 2 (rev Sept2014)