Population approach Example, CIPHA (Combined Intelligencefor Population Health)

Population Health management digital platform to provide actionable insight into epidemiology, prevention and management of HF

Real-time dashboard with monitoring and tracking of data regarding prevalence of cardiovascular risk factors for HF (hypertension, diabetes, ishcaemic heart disease, obesity, hyperlipidemia etc)

Other analyses include health needs analysis to understand health outcomes and deficits, analysis of socio-economic inequalities and impact on population health outcomes

Predicting development of HF and adverse outcomes

Intensification of management of risk factors (HTN, DM,IHD, hyperlipidemia)

Create intelligence to improve outcomes, reduce inequalities

Understanding causality of dissease (heart failure)

Case finding software

Electronic case-finding of patients with cardiovascular risk factors (hypertension, diabetes, IHD, hyperlipidaemia)

Pick-up of historical cohort of HF patients – reassess suitability for device, Improved management of multimorbidity and therefore prevention of heart failure

Smart stethoscope

AI enabled stethoscope, ECG to predict LVEF

Availability and training in Primary care

Rapid diagnosis in the community

Case finding software

Electronic case-finding of patients with cardiovascular risk factors (hypertension, diabetes, IHD, hyperlipidemiap)

Pick-up of historical cohort of HF patients – reassess suitability for device, Improved management of multimorbidity and therefore prevention of heart failure

Virtual wards

A virtual ward is a safe and efficient alternative to NHS bedded care that is enabled by technology. Virtual wards support patients who would otherwise be in hospital to receive the acute care, monitoring and treatment they need in their own home. This includes either preventing avoidable admissions into hospital or supporting early discharge out of hospital.

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7 day week service (8AM-8PM), includes ambulatory or home IV diuretics

Patient Care Plan with clear pathways for out of hours provision and pathway in case of “Red flag” symptoms or signs of deterioration (based on traffic light based system of HF symptom monitoring)

Remote monitoring equipment to transmit daily symptoms, clinical parameters using a tablet APP to a Telehealth Hub monitored by specialist nurses

Specialist nurses/ACPs to review, interpret and action findings

Home IV diuretic delivery provision/ Ambulatory unit/Same day emergency care (SDEC) to deliver IV diuretics

Clear pathways to enable rapid review of unwell patient (A&E, Hot Clinic, Ambulatory Unit, community clinic)

A Heart Failure Clinician led Multi-Disciplinary team (MDT) who deliver daily virtual ward round, nurse-telephone support and face to face review if indicated. The patient is under the care of a named Consultant Cardiologist.

Robust documentation to ensure clinical governance, roles and responsibilities, accountability and escalation.

Patients managed in their own home surroundings

Reduced risk of problems due to hospitalisation (such as hospital acquired infection, delirium, falls, undernutrition, reduced mobility and functional capacity)

Hospital beds freed up for sicker patients

Potential cost savings

Hospital at Home

Hospital at Home provides intensive, hospital-level care for acute conditions that would normally require an acute hospital bed, in a patient’s home for a short episode through multidisciplinary healthcare teams. May or may not utilise remote monitoring technologies.

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IV team trained in delivery of IV diuretic in home/ambulatory unit/ community hub with provision for daily monitoring of renal function and electrolytes (preferably point-of-care testing)

24/7 access to care. MDT consisting of Nurses and therapists with clinical oversight from a lead physician

Patients managed in their own home surroundings

Reduced risk of problems due to hospitalisation (such as hospital acquired infection, delirium, falls, undernutrition, reduced mobility and functional capacity)

Hospital beds freed up for sicker patients

Potential cost savings

Self-care app
Example – Aintree Heart Failure Passport (free NHS app)

A health based educational app, used to provide traffic-light based symptom monitoring guidance, prompts for medication, appointment and mood monitoring for patients with Heart Failure

Patient/carer will need a smartphone/tablet (which can also be provided)

Improved patient education and self-care

Remote monitoring dashboard (Long term conditions monitoring service

A patient App, Bluetooth enabled devices i.e. BP and scales upload to RM dashboard for nurses/pharmacists to review daily. Support patient education and self-management. Enable remote review and optimisation, early detection of decompensation to prevent admission, enhance usual care. Potential in PIFU.

Smart phone/computer/tablet. Funding for equipment and licence to use App.

Specialist nurses/pharmacists to review dashboard.

Usually not a 7/7 service as usual commissioned service.

Early detection of decompensation, leading to escalation of therapies and thereby prevention of HF hospitalisation

Implantable cardiac devices

Remote downloading from certain devices can activate alerts with regards to fluid status or arrythmia

Device specific. Requires staff i.e. physiologists/HFSN to monitor dashboard and responds appropriately

Device specific

Remote monitoring or App-based advice and prompts

Patients offboarded from remote monitoring could continue to utilise it for self-care and self-monitoring, escalating to GP or HF team using RAG signs and symptom checker. PIFU pathway.

A patient App, Bluetooth enabled devices i.e. BP and scales upload to RM dashboard for nurses/pharmacists to review daily. Support patient education and self-management. Enable remote review and optimisation, early detection of decompensation to prevent admission, enhance usual care.

Early detection of decompensation, leading to escalation of therapies and thereby prevention of HF hospitalisation.

As for remote monitoring, virtual ward and Hospital at home

As for remote monitoring, virtual ward and Hospital at home

Robust community nursing, palliative team support for palliative symptom relief including use of medications delivered via syringe driver

End of life care in location preferred by patient (if home -in their home surroundings and company of family

Apps

Web-based or apps providing general advice on health or wellbeing

IT device/smartphone required (can be provided)

Ideal for signposting support - but for mild symptoms only