Project Name: ASCVD community-based lipid optimisation with Maidstone and Tunbridge Wells Trust
Project Summary:
The CWP is structured such that a multi-disciplinary health professional team will provide tailored care for patients, aligned with the Primary Care Network (PCN) Contract Direct Enhanced Service (DES) and the Locally defined Cardiovascular plans.
The main objective of the CWP is to improve the quality of care for patients and support the early identification, review, and medical optimization of patients with atherosclerotic cardiovascular disease (ASCVD) who are at high risk of cardiovascular events and who are not achieving lipid levels as specified in national and/or local guidance. In response to the needs of the CW Partner, Novartis will contract with Maidstone and Tunbridge Wells NHS Trust as the legal entity.
The CWP will be led by a Clinical Pharmacist band 8b alongside a multi-disciplinary team; including Maidstone and Tunbridge Wells (MTW) Consultants and specialist teams in Metabolic Medicine, Stroke Care and PCN Clinical Pharmacists and General Practitioners aiming to achieve:
- Identification of sub-optimally treated ASCVD patients (secondary prevention) who are at high risk of another cardiovascular event and are not achieving lipid levels as specified in national and/or local guidelines
- Identification of ASCVD patients who are at higher risk of cardiovascular events and who have previously not tolerated or refused alternative lipid modification therapies (secondary prevention)
- Review of treatment options and decision on next steps in collaboration with ASCVD patients
- Counsel and optimise ASCVD patients where appropriate including other modifiable risk factors, including health and wellbeing advice (non-pharmacological interventions)
- Early identification of secondary prevention ASCVD at-risk patients who have not had intervention in their health and wellbeing.
- Identification of ASCVD patients, following risk assessment review, who are sub-optimally treated.
- On-going ASCVD patients support and annual review to ensure CVD outcomes improve equitably
The Trust will ensure review of high risk ASCVD patients (secondary prevention) as detailed above in the following PCNs
- ABC PCN
- Malling PCN
- Tunbridge Wells PCN
Planned Milestones:
| Milestone | Description |
|---|---|
| 1 | Kick off meeting Baseline Data |
| 2 | Confirmation of clinical and operational pathway, policy and protocol creation. |
| 3 | Confirmation of recruitment and on boarding of Band 8b Clinical Pharmacist (CW Partner shall ensure that the clinical staff covered by the Novartis Financial Contribution are in place, trained and ready to begin clinical activity). |
| 4 | Clinical Audit and Clinical Audit Discussion with Member Practices |
| 5 | Collection & submission of 3 months clinical activity data. |
| 6 | Collection & submission of 6 months clinical activity data. |
| 7 | Collection & submission of 9 months clinical activity data. Initiation of development of business case to support service offered by this project |
| 8 | Collection & submission of 12 months clinical activity data. |
| 9 | Submission of business case to continue the service offered by this project |
| 10 | Analysis of CWP data, submission of Final Project Report, Submission of Outcomes Summary |
Expected Benefits:
Anticipated benefits for patients:
- Improved access to lipid management care leading to optimal diagnosis and management of ASCVD treatments.
- Enhanced experience around ASCVD with ongoing management of the condition.
- Improved access to appropriate medication for suitable patients to preserve health and prevent long-term events
- Easier access to lipid management care closer to home in the Primary Care setting
- The additional capacity will provide additional time and support from PCN HCP with their lipid management, focusing on patients who may have previously not attended a GP appointment or been lost to follow-up.
- Provide specialist expertise to help address public health and social care needs of patients to tackle health inequalities,
Anticipated benefits for the CW Partner:
- Increased proportion of ASCVD patients reviewed by primary care
- Increased proportion of ASCVD patients receiving expert and timely review closer to home
- Reduction in ASCVD referral rates to secondary care
- Increased proportion of patients receiving guideline-directed pharmacotherapy
- Insight into benefits of a pharmacist led lipid management clinics in primary care
Anticipated benefits for Novartis:
- Insight on the appropriate use of ASCVD licensed medicines in line with NICE guidelines, including Novartis’s medicine
- Enhanced reputation, and supporting Novartis’ vision that no patient should have to wait for an extraordinary life, by supporting high quality Collaborative Working with healthcare organisations which addresses the problem of health inequalities
- Ethical, professional, and transparent relationship between Novartis and the Healthcare Organisations
Start Date & Duration: November 2023 for 18 months
UK2311272313