Getting the heart tick

1 July 2013

After lagging at the bottom, Western Bay of Plenty PHO is now perched at the top of the ‘more heart checks’ performance table. FIONA CASSIE talks to RN and general practice coordinator Donna McArley on getting the heart tick and moving on to managing those highlighted as being at risk. She also talks to outreach clinical nurse leader Sue Matthews about doing heart checks at truck stops to freezing works.

Fighting heart disease is more than just ticking off boxes on a checklist.

But if you aren’t ticking the boxes in the first place, it’s much harder to highlight those needing help to manage their heart disease risk.

Three years ago Western Bay of Plenty Primary Health Organisation (PHO) found itself lagging at the bottom of the league table with only 30 per cent of its eligible patients receiving a cardiovascular disease (CVD) risk assessment.

With 44,000 patients eligible for checks – nearly a third of its enrolled population of 145,000 people – the PHO set up a clinical committee to turn this lacklustre performance around.

Donna McArley (left), the PHO’s general practice coordinator, says the low reporting levels were the result of both electronic barriers and the need for a PHO-wide focus.

The electronic challenge for the large PHO – it has 27 practices with about 160 GPs and 150 nurses – was it had four different practice management systems and no electronic tool to calculate and record CVD risk.

So the PHO had the ‘best practice’ decision support tool installed across three of the four systems and then rolled out to the fourth so it wasn’t reliant on manually extracting data.

McArley says once the PHO had a better data picture of how practices were performing, she highlighted the ten worst performers and went out and met with all of the practices’ staff – not just the GPs and nurses but also the administration staff, “as it needs a team effort to meet health targets.”

She says each practice had a CVD target champion put up their hand – in some practices, it was a GP, and in others, it may have been a nurse already offering nurse-led clinics – and they were the drivers for change. And change the practices did, with the PHO becoming the highest performing PHO at the end of 2012 with a 75.6 per cent CVD risk assessment rate.

“All the practices have demonstrated quite a significant improvement since we addressed the issue. It has lifted us up from our abysmal record of being right at the bottom of the league table to the top.”

Offering CVD risk assessment training to nurses across the PHO and the resulting increase in nurses carrying out opportunistic CVD risk assessment contributed greatly to that improvement. McArley says nurses and GPs being ready to grab the moment is really the only way to carry out CVD risk assessments as there is no subsidy available and people aren’t likely to pay-up to see their doctor or nurse unless they are unwell or need a prescription renewed.

The difficulty is capturing those at risk groups – often male and working – which is why the PHO also funds Kaitiaki Nursing Services and its mobile nursing team who stake CVD and diabetes risk assessment into people’s workplaces (on page 11).

What next after ticking the boxes?

“Just doing CVD risk assessments alone is meaningless,” says McArley.

“But we have to get everybody assessed and recorded so we can identify whose actually at clinical risk.”

She says the PHO is very conscious that just topping the check league table is not enough and the PHO’s practices must also be prepared to be measured on how well they are managing the CVD high risk patients the checks reveal.

It is also well aware that cost was another obstacle for at-risk patients. So the PHO has recently approved allocating some discretionary funding so general practices can regularly see their high risk patients and help them manage their CVD risk.

With limited funds available, it was decided to target only those who were 55 years or younger and had a CVD risk of greater than 15 per cent – a cohort of about 3000 patients. She says setting this age target means it can offer a meaningful programme of about four patient visits a year and also capture the younger Māori demographic, which statistics show are some of the most at risk. “If we can get those (high risk) patients in their 40s and get them managed well, hopefully we can improve their outcomes.”

In return, the practices will need to provide regular blood pressure and lipid levels data – as well as information on what new medications the patient has been prescribed – so the PHO can measure how well they are managing.

She says it will be left up to practices to decide what combination of GP and nurse care is offered to the CVD patients but with prescribing and monitoring new medications a major part of CVD management she envisages it is likely patients will be offered combined care with nurses particularly focusing on helping patients manage lifestyle risk factors.

Patients can also be referred to a PHO-funded Sports Bay of Plenty programme that is a combined self-management and green prescription programme covering nutrition and exercise for people with a CVD risk of more than 14 per cent. The CVD risk assessments include the diabetes check component, which is leading to practices picking up patients with impaired glucose tolerance (IGT) or pre-diabetes, and these people can also be referred to the green prescription programme.

Because McArley says the PHO is not content with just having jumped the league table ranks in assessing and finding the patients at high CVD and diabetes risk, it is now also aiming to be “ahead of the game” in helping those people keep well. And it’s pretty keen to top that league table, too.