Pan London AF Improvement Programme

• What are the Programme aims?

• What does the programme entail?

• What are the expectations of participants?

Helen Williams,

Consultant Pharmacist for CV Disease – South London and

Clinical Director for AF, Health innovation Network

Pan London economicmodelling

Up to 2000strokes

prevented

£3.5mcumulative net

savings

Up to 450lives saved

To prevent AF-related stroke and associated mortality through betteridentification and management of people with atrial fibrillation

Increasing anticoagulation of untreated high risk AF patients

Improving the quality of anticoagulation

Increasing the detection of undiagnosed AF in high risk patients

Programme aims

Measurable Outcomes

PAN LONDON AF QUALITY STANDARDS

• > 80% (no exceptions) of patients with a CHA2DS2VASc score ≥ 2 on anticoagulation treatment

• < 10% (no exceptions) of patients with a CHA2DS2VASc score ≥ 2 on anti-platelet treatment

• 100% of patients taking warfarin with a TTR < 65% who have their anticoagulation quality reassessedat least once every six months

• > 90% of patients over 65 who have a pulse check (manual or other technology) over 5 years

AGREED SYSTEM LEVEL IMPACT MEASUREMENT

• Lives saved (reduction in number of patients who died as a consequence of a stroke)

• Reduction in number of AF-related stroke episodes

AHSN ‘SET UP’MEETINGSWITH EACH

CCGJUNE/ JULY

½ DAY LAUNCHEVENT

6th JUNE

1st QUARTERLYCOLLABORATIVE

EVENTSEPTEMBER

Purpose: Review progress Share learning Problem solve Plan ahead

Purpose: Interested CCG will

select their localpriorities forimprovement

Purpose: Launch improvement

programme & toolkit Share practical case

studies Consider improvement

opportunities

2ND QUARTERLYCOLLABORATIVE

EVENTDECEMBER

3RD QUARTERLYCOLLABORATIVE

EVENTMARCH

4TH QUARTERLYCOLLABORATIVE

EVENTJUNE6 wkly Plan

& Reviewmtg witheach CCG

6 wkly Plan& Reviewmtg witheach CCG

6 wkly Plan& Reviewmtg witheach CCG

Programme elements

Toolkit elements

Steps

DET

ECT:

Fin

din

gm

ore

AF

-D

evi

ces

1. Prepare

2. Diagnose

3. Plan &Implement

4. Measure &Refine

Activities Data, tools and materials

Secure resources

Build a project team

Agree project governance

Business case

Clinical lead, Project manager, Patient representative, Clinicians

Accountability, Reporting, Issue/ risk management

Routine Monitoring

Audit

Review

Annual QOF, manual submission of data according to local schemes

Practice level, CCG level

Practice visits

Assess current performance

Engage stakeholders

Select from models of good practice

Assess staff readiness for change

Collect baseline data

Set realistic aims/ standards

Create enablers

Build capability

NICE standards, QOF – AF detected prevalence vs expected prevalence

Primary care (GPs, community pharmacists, outreach team)

Case studies of successful models using devices in practice, comparison of devices available

Prior knowledge and skills – gap analysis

CCG / practice level prevalence vs expected prevalence

Number of pulse checks using device or % increase in AF register size at practice / CCG level

Incentives – LES , GP delivery plan, digital infrastructure, devices and technology

Training, protocols, guidelines, patient information

IWhat is expected ofparticipants?

Implementation

Set up phase

Prioritise

Select improvement priority Collect baseline data

Secure project managementAppoint clinical leadership

Partake in improvement community Measure improvement real time

Any Questions?

Additional slides in case you want to use them

Plus editable version of toolkit as the one is main slides is a photo

Improvement opportunities

DETECT

Detect those withundiagnosed AF

PROTECT(& CORRECT)

Protect those withdiagnosed AF

through effectivetreatment

PERFECT

Optimise thetreatment of peopleon anticoagulation

Improvement activities Scope

Build awareness and skills amongst people at high risk of AF and their families: knowing yourpulse, and providing opportunistic pulse checks and AF screening in community settings.

Use manual pulse checking in routine practice and/or within opportunistic screeningprogrammes for high risk patients as part of the national Health Checks programme withinprimary care settings (e.g., pharmacy, General Practice).

Use inexpensive devices to detect and diagnosis AF in primary care settings (e.g., pharmacy,General Practice) either as part of routine practice and/or within opportunistic screening ofhigh risk patients 65.

Increase anticoagulation (incl. risk

factor management & decreasing aspirin)

Initiate anticoagulation in primarycare (incl. risk factor management)

Heart rate and rhythm control

Review general practice registers to identify people with AF to increase the proportion onanticoagulation (versus aspirin), to manage risk factors and where relevant, to reduce thoseinappropriately exception reported.

Transfer initiation of anticoagulation (warfarin and direct anticoagulants, DOACs) andmanagement of risk factors to a primary care setting with appropriate clinical governance andensuring seamless ongoing management for people anticoagulation therapy.

Provide guidance for patients and primary care clinicians on measures to take with regards torate and rhythm control.

Assure quality and capacity of existing local monitoring and management services for patientson oral anticoagulant therapy.

Offer people with AF the opportunity to self-monitor their INR and self-manage theirwarfarin.

Provide adherence support to people at risk of non-adherence, such as, newly diagnosedpeople on a OACs through existing service pathways or use of primary and community basedservices (e.g., community pharmacists)

Awareness campaigns

Pulse checks

Devices

Anticoagulation management

Self monitoring and management

Anticoagulation adherence

Model for improvement

•Patient and clinical insights•Local outcome and economic modelling based on NICE costing tool

Compelling casefor change

• Improved QOF points

• Examples from elsewhere e.g., LES, Quality Premiums, commissioning intentions

• Models of care mapped e.g., pharmacy-led schemes, virtual clinics, hub & spoke

Commissioninglevers

•Provision of guidelines and education sessions•Training on practical tools for screening, case finding, diagnosis, adherence etc.•Facilitating engagement across primary, community and secondary care

Primary caresupport tools

• Set of metrics to track improvement

• Dashboards showing improvement over time and variation at practice and CCG level

Measurement forimprovement

• Bespoke support tailored to locally determined priorities

• GP leadership development

• Communities of practice for common priorities to enable peer-to-peer learning

Bespoke & peer-to-peer learning

Investment required

NHSE and LA Support Required:1. Levers and incentives:

• Commissioning intention & Quality premium• Recommend CCG AF quality dashboard Support

implementation of quality standards integrated intoprovider contracts for anticoagulation and AF services

2. Additional drug spending (moving from currenttreatment to better anticoagulation rates as per NICEpredictions) £12-£15m per year

3. Transformation resources*

4. Total year 1 upfront investment ~£17m (thoughroll-out likely to be phased over 18-24months)**

Principles for Replication for other LongTerm Conditions:This programme creates improvement across the whole AFpathway. The delivery model includes partnership working (peerto peer networks, shared learning collaboratives), patientengagement and new models of care (hub and spoke, pharmacyled schemes, virtual clinics, self-management). Potentialsynergies for other LTCs may arise in the following areas:

1. Commissioning levers: Devising of quality standards (e.g.for warfarin clinics) and use of commissioning incentives (e.g.quality premium / LIS) to drive improvements in primary care.

2. Measurement & dashboards: Supportingimplementation at a CCG level of the collection and tracking ofbenchmarked data on any disease pathway. Data licence onlyneeds buying once.

3. Education: Utilising reserved education time for a rollingprogramme of LTC upskilling.

*partly recurrent e.g. IT licence and ongoing education but at lower level; **total drug costs may be capped as part of the local PPRS arrangement, tbc

Resource Cost perCCG

London cost(32 CCGs)

CCG clinical leadership (0.2wte) £27,650 £884,800

CCG Practice Facilitator (0.2wte) £9,870 £315, 830

IT licence and data analysis £18,250 £584,000

TOTAL £55,770 £1,784,630