Cardiac RehabilitationCardiac RehabilitationCardiac RehabilitationCardiac Rehabilitation

h ih iInto the Future in East Into the Future in East LancashireLancashire

Susan Warburton, MSc, RGN

Commissioning Manager for Long Term Conditions

‘If there was a pill that cost very little, reduced ‘If there was a pill that cost very little, reduced cardiac deaths by 27 per cent improved qualitycardiac deaths by 27 per cent improved qualitycardiac deaths by 27 per cent, improved quality cardiac deaths by 27 per cent, improved quality of life, and reduced anxiety and depression, of life, and reduced anxiety and depression, every patient in Europe would be expected to every patient in Europe would be expected to y p p py p p ptake it. take it.

There is no such pill, but taking part in a cardiac There is no such pill, but taking part in a cardiac rehabilitation programme can provide all of these rehabilitation programme can provide all of these benefits in the UK only a small number of thosebenefits in the UK only a small number of thosebenefits, in the UK only a small number of those benefits, in the UK only a small number of those in need are offered the chance to take part in it”in need are offered the chance to take part in it”

(Professor Lewin, European Society of Cardiology, Amsterdam 2005)(Professor Lewin, European Society of Cardiology, Amsterdam 2005)

Redesigning services for CRRedesigning services for CR

Strategic priority to improve health inequalities and accessStrategic priority to improve health inequalities and accessCare Closer to Home programmeCare Closer to Home programmeCare Closer to Home programmeCare Closer to Home programmeService set up in 1996Service set up in 1996Service has not been reviewed since 2002Service has not been reviewed since 2002Service part of the wider acute contractService part of the wider acute contractService part of the wider acute contractService part of the wider acute contractConcern raised by CHD LIT re poor uptakeConcern raised by CHD LIT re poor uptakeNST recommended review “one size doesn’t fit all”NST recommended review “one size doesn’t fit all”Review of cardiac rehabilitation services part of Cardiac Review of cardiac rehabilitation services part of Cardiac strategy of Lancashire and Cumbria Cardiac and Stroke strategy of Lancashire and Cumbria Cardiac and Stroke NetworkNetwork

Exam Question: How do we encourage this group to participate?

Current Situation (April 2007Current Situation (April 2007--MarchMarchCurrent Situation (April 2007Current Situation (April 2007 March March 2008)2008)

DiagnosisDiagnosis AdmissionsAdmissions Referrals to CRReferrals to CR

MIMI 791791 768768MIMI 791791 768768

PCIPCI 145145 371371

CABGCABG 168168 266266

Heart FailureHeart Failure 447447 1414

ICDICD 1111 00

OtherOther 171171

Total referredTotal referred 15621562 15761576

Data SourceData Source HESHES NACRNACR

What is the current activity?

Admissions: Angina 1054 ICD 14 (2009/10)

Heart Failure 722Heart Failure 722

Vascular 703

What else?What else?What else?What else?Total number of referrals 2008/9Total number of referrals 2008/9Total number of referrals 2008/9Total number of referrals 2008/914261426Patient referralPatient referral

Average age of patient Male 64 Female 70Average age of patient Male 64 Female 70Average by gender Male 67.4% Female 32.6%Average by gender Male 67.4% Female 32.6%Eth iEth i Whit 59 3% N t St t d 31 5% BME 5 2%Whit 59 3% N t St t d 31 5% BME 5 2%Ethnic group Ethnic group -- White 59.3% Not Stated 31.5% BME 5.2%White 59.3% Not Stated 31.5% BME 5.2%

Phase 3 Rehab 08Phase 3 Rehab 08--0909Phase 3 Rehab 08Phase 3 Rehab 08--0909532 532 37% of referrals into complete phase 3 programme37% of referrals into complete phase 3 programme271 continue to go to longer term health programmes (19%)271 continue to go to longer term health programmes (19%)

*Data-NACR database

Assessing NeedsAssessing Needs

Effective engagement Effective engagement –– the ‘customer’ isn’t just the ‘customer’ isn’t just the public but can also be professionals and localthe public but can also be professionals and localthe public but can also be professionals and local the public but can also be professionals and local politicianspoliticiansReviewing current provisionReviewing current provision--know what you haveknow what you haveSocial Marketing Social Marketing –– segmenting marketsegmenting marketPatient Mapping/ForumsPatient Mapping/ForumsClinical team process mappingClinical team process mappingNICE Commissioning toolNICE Commissioning toolCurrent evidence/different models of serviceCurrent evidence/different models of serviceInvestigation different models of serviceInvestigation different models of service

“Patient Story” Event“Patient Story” Event

2 events in June 09 (Blackburn & Burnley)2 events in June 09 (Blackburn & Burnley)Home visits and letters from service usersHome visits and letters from service usersVisit to BME communityVisit to BME communityVariance in quality of experienceVariance in quality of experienceImprovement in communications across the pathwayImprovement in communications across the pathwayR t f t d di d i f tiR t f t d di d i f tiRequest for standardised informationRequest for standardised informationSome didn’t know about cardiac rehabilitationSome didn’t know about cardiac rehabilitationMultiMulti--agency discharge planning/multi agency support once homeagency discharge planning/multi agency support once homeServices need to be more convenient and localServices need to be more convenient and localServices need to be more convenient and localServices need to be more convenient and localHome support for those unable to attend or not wanting to attend gymHome support for those unable to attend or not wanting to attend gym--older generation not used to gymolder generation not used to gymSuggestion that Healthy Lifestyles should intervene right from the start ie.Suggestion that Healthy Lifestyles should intervene right from the start ie.Suggestion that Healthy Lifestyles should intervene right from the start ie. Suggestion that Healthy Lifestyles should intervene right from the start ie. Before surgeryBefore surgeryActivities tailored to individualsActivities tailored to individualsPositive experience for most people who had engaged with the servicePositive experience for most people who had engaged with the service

Professional “Gold Standard” EventProfessional “Gold Standard” Event

Held in October 2009Held in October 2009Single point of accessSingle point of accessSingle point of accessSingle point of accessClear signpostingClear signpostingPersonalised care e g own gym tailored programmesPersonalised care e g own gym tailored programmesPersonalised care e.g own gym, tailored programmesPersonalised care e.g own gym, tailored programmesImprovements in communication across pathwayImprovements in communication across pathwayIntegrated service with wider range of professionalsIntegrated service with wider range of professionalsIntegrated service with wider range of professionals Integrated service with wider range of professionals Lifestyle coachingLifestyle coachingAftercare and ongoing support up to 12 monthsAftercare and ongoing support up to 12 monthsg g pp pg g pp pProvision of psychological supportProvision of psychological supportUsing technology to support interactionUsing technology to support interaction

Local GP’s commentsLocal GP’s comments

Linked with Exercise on PrescriptionLinked with Exercise on PrescriptionOne contact point for referralOne contact point for referralFeedback in standardised formatFeedback in standardised formatFeedback in standardised formatFeedback in standardised formatPersonalised plans for patientsPersonalised plans for patientsLocality based Locality based Linked with other CVD professionalsLinked with other CVD professionals oneoneLinked with other CVD professionals Linked with other CVD professionals –– one one CVD primary care teamCVD primary care team

RedesignRedesign

“When you’re not just thinking “When you’re not just thinking y j gy j goutside the outside the

b b t t ll b ildib b t t ll b ildibox, but actually building a new box, but actually building a new box, box, ,,

you don’t always fit the current you don’t always fit the current way way

of doing things!”of doing things!”of doing things!of doing things!

East Lancs CVD Health Improvement Pathway

Referral meeting criteria from primary, secondary and tertiary careto centralised referral system

18 Weeks

CVD Health Improvement team contact individual by agreed method within 5 workings days or discharge or referral

Support

Heart

Health

Personalised health planning appointment – will take place inl li l i di id l h

Improvement

Pathway

locality closest to individuals home

East Lancs CVD Health Improvement Pathway

MENU BASED APPROACH18 Weeks

Education sessionsrelating to individual H B d

Group based exercise and

Wellbeing

Support

Heartrelating to individual

outcome goals –Multiple provision

modes

Home Basedprogrammes

WellbeingProgrammes –

Multiple provision modes

Health

Improvement

Pathway

East Lancs CVD Health Improvement Pathway

8 week individual follow up by personal facilitator/health coach

Signposting individual to continued18 Weeks

Signposting individual to continued health and well being programmesSupport

Heart

Locality based and Virtual Support

Long TermPhysical

Primary Care:Ensuring

Health

Virtual SupportGroups –

e.g. Facebook, Twitter groups

PhysicalActivityand well

being

gLong term structured secondary

Improvement

Pathway

Twitter groupsetc

beingprogrammesprevention

follow up

East Lancs CVD Health Improvement Pathway

18 Weeks

Support

Heart

Health

6 and 12 month follow up

Improvement

6 and 12 month follow up by personal health coach

Pathway

Continued support toMaintainMaintain health goals

Key Features of Proposed ServiceKey Features of Proposed Service

CoCo--location of teams in location of teams in localities,closer to home localities,closer to home

Use of technology to support Use of technology to support people in their own homes e.g people in their own homes e.g self help/eself help/e supportsupportNamed supportNamed support

Single contact pointSingle contact pointBroader inclusion criteriaBroader inclusion criteria

self help/eself help/e--supportsupportLonger opening hoursLonger opening hoursVocational assessment as Vocational assessment as requiredrequiredPersonalised planPersonalised plan

More choice of activities and More choice of activities and support e.g ed. sessionsupport e.g ed. session

requiredrequiredHealth coaching and contact Health coaching and contact for 12 monthsfor 12 monthsHome programmesHome programmesBroader range of professionals Broader range of professionals

to drawn for expertise e.g pul. to drawn for expertise e.g pul. rehabrehabN l A iN l A i

Home programmesHome programmesStandardised informationStandardised informationReview at 12 months and Review at 12 months and update if requiredupdate if requiredNew roles e.g Assistant New roles e.g Assistant

PractitionersPractitionersupdate if requiredupdate if requiredClear outcomes being Clear outcomes being monitoredmonitored

The Inpatient PhaseThe Inpatient Phase

Written and Verbal Education regarding Coronary Heart Disease and CardiacWritten and Verbal Education regarding Coronary Heart Disease and CardiacWritten and Verbal Education regarding Coronary Heart Disease and Cardiac Written and Verbal Education regarding Coronary Heart Disease and Cardiac RehabilitationRehabilitation

Assessment of Physical, Psychological and Social needsAssessment of Physical, Psychological and Social needsInitial Lifestyle and Risk Factor Modification adviceInitial Lifestyle and Risk Factor Modification advice

Chest Pain and GTN AdviceChest Pain and GTN AdviceAn individualised Cardiac Rehabilitation Plan including a Graded Activity PlanAn individualised Cardiac Rehabilitation Plan including a Graded Activity Plang yg yPrescription of Appropriate Cardiac Medications and Education about their usePrescription of Appropriate Cardiac Medications and Education about their use

Cardiac Physiotherapy Assessment as appropriate.Cardiac Physiotherapy Assessment as appropriate.Involvement of CarersInvolvement of CarersInvolvement of CarersInvolvement of Carers

Information about local cardiac support groupsInformation about local cardiac support groups

Early Post Discharge PhaseEarly Post Discharge Phase

Either a Home Visit or Telephone Consultation is offered where discussion takesEither a Home Visit or Telephone Consultation is offered where discussion takesEither a Home Visit or Telephone Consultation is offered where discussion takes Either a Home Visit or Telephone Consultation is offered where discussion takes place regarding the following:place regarding the following:

Assessment of Physical Psychological and Social NeedsAssessment of Physical Psychological and Social NeedsAssessment of Physical, Psychological and Social NeedsAssessment of Physical, Psychological and Social NeedsGoal SettingGoal Setting

Lifestyle Advice Regarding: Physical Activity, Diet, Cholesterol, Weight Lifestyle Advice Regarding: Physical Activity, Diet, Cholesterol, Weight Management, Smoking Cessation, Alcohol Consumption, Employment, Driving, Management, Smoking Cessation, Alcohol Consumption, Employment, Driving,

Sexual Activity, Holidays, InsuranceSexual Activity, Holidays, InsurancePrescription of and Education on MedicationsPrescription of and Education on Medications

Chest Pain and GTN advice Chest Pain and GTN advice Discussion of options for further supportDiscussion of options for further support

The MenuThe Menu

Is offered to post MI post CABG or Valve Surgery post ICD insertionIs offered to post MI post CABG or Valve Surgery post ICD insertionIs offered to post MI, post CABG or Valve Surgery, post ICD insertion, Is offered to post MI, post CABG or Valve Surgery, post ICD insertion, post PCI when clinically stable post PCI when clinically stable

It is also offered to newly diagnosed stable angina patients. A menu of It is also offered to newly diagnosed stable angina patients. A menu of individualised options is available for patients to choose from The Menuindividualised options is available for patients to choose from The Menuindividualised options is available for patients to choose from. The Menu individualised options is available for patients to choose from. The Menu

includes:includes:6 week community based cardiac rehabilitation programme6 week community based cardiac rehabilitation programme

Heart Manual/Heart Failure Manual/Angina PlanHeart Manual/Heart Failure Manual/Angina PlanRoad to RecoveryRoad to Recovery

Weight Management ProgrammeWeight Management ProgrammeWeight Management ProgrammeWeight Management ProgrammeOne to one support from health coachOne to one support from health coach

Healthy Minds GroupHealthy Minds Group

The Menu Continued…The Menu Continued…

One to one support from health coach/personal trainerOne to one support from health coach/personal trainerOne to one support from health coach/personal trainerOne to one support from health coach/personal trainerBuddy SchemeBuddy SchemeRelaxation CDsRelaxation CDs

PedometersPedometersHealthy @ Heart Health WalksHealthy @ Heart Health Walks

Fast Track to more appropriate sessions if clinically suitableFast Track to more appropriate sessions if clinically suitablepp p ypp p ySignposting to other services, such as Citizens Advice Bureau etcSignposting to other services, such as Citizens Advice Bureau etc

Onward ReferralOnward Referral

Progression to Long Term Maintenance programmesProgression to Long Term Maintenance programmesProgression to Long Term Maintenance programmes.Progression to Long Term Maintenance programmes.

Next StepsNext Steps

ReRe--investment plan being worked upinvestment plan being worked upProcurement action plan being developedProcurement action plan being developedProcurement action plan being developedProcurement action plan being developedImplementation of final service by end of Implementation of final service by end of the year.the year.