We have developed a sophisticated, interactive, password-protected secure cardiac rehabilitation (CR) website,'Activateyourheart', to increase capacity and choice associated with the delivery of CR. In addition we have taken a different approach to delivering our educational component of phase three CR to ensure our patients have much more timely access to information about heart disease, treatments, symptom management, medications, diet and exercise with a much greater emphasis on behaviour change using principals of motivational interviewing. This has increased choice for patients; proved accessible for people who otherwise would not have participated; reduced waiting times for education sessions and released capacity.
This example was originally submitted to demonstrate implemention of NICE CG172. This guidance has now been updated and replaced by NICE NG185. The example has been reviewed and its content continues to align generally with the updated guidance. The latest NICE guidance should be referred to if replicating any aspect of this example.
- Acute coronary syndromes (NG185)
Aims and objectives
The incidence of coronary heart disease (CHD) is set to rise by 17% by 2014. CR is recognised as one of the most effective interventions to help individuals with cardiac disease return to a full and active life, thus influencing the likelihood of a subsequent cardiac event and associated hospital admissions. NICE guidance including the most recent on acute coronary syndromes (NG185, recommendation 1.8) recommends referral to a CR programme, however uptake is still low.
The National Audit of Cardiac Rehabilitation (2011/12) shows that whilst year on year uptake to CR is improving, less than half of eligible people (43%) access a programme which falls far short of the CVD Outcomes Strategy for England target of 65% uptake.
Standard CR is a supervised exercise and education out-patient package, extending 6-8 weeks. Reasons for poor uptake included travel and the need to return to work. There is a lack of effective and appealing alternative models, minimising realistic choice.
We aimed to build on a locally inspired improvement idea to develop two workstreams, an interactive website for CR delivery in combination with a new approach to delivering the educational component of the existing CR programme in response to patients/service users' feedback.
Our objectives were to increase:
- Choice for CR (making the best use of resources)
- Uptake of CR in the East Midlands
- Capacity for CR within the team.
By doing this we hoped to provide earlier engagement for patients in CR by providing much more timely access to the educational component of phase 3 and improve uptake rates for individual assessment.
Reasons for implementing your project
Audit of our local CR programme showed we had similar results to the country as a whole in access and uptake to CR. This gave us the impetus to drive change and improve our impact and productivity as a team.
Feedback from patients indicated that many people prioritised returning to work over attendance on a CR programme and we explored alternative ways of enabling people to do this and still access the service. In our scoping of the development of the website we identified that there was an existing group of patients who do attend for CR who would also be happy to access online, thus releasing additional time for more complex patients to receive more timely access to the service
We also identified that there was potential for more focused approached to education with a greater emphasis on behaviour change and consultant endorsement for CR programmes. The educational component traditionally was delivered at point when patients started their conventional hospital delivered phase 3. Due to service demand and capacity issues this would on average take 11 weeks by which time patients would either decline through lack of early engagement or felt they no longer needed the service and as a consequence not avail the benefits of CR.
The project team believed that adoption of technology would enable the CR service to deal more effectively with an aging population and respond to consumer demand for accurate internet based knowledge and access to healthcare professionals. The project was designed to provide accurate and creditable information and advice to empower the individual and provide a forum for shared experience and exchange of knowledge between patients. To date this technology has not been adopted within CR.
How did you implement the project
A working group was established to ensure effective communication between the two workstreams and this met on a monthly basis. Each workstream held regular weekly project team meetings where issues on progress were discussed and actioned.
Funding for the development of the website was achieved by a Health Foundation SHINE innovation award and the contract was awarded as a result of an invitation to tender. Internal funding was used to develop a DVD for the new approach in delivering education to our CR patients; this included filming of patient testimonials, consultant endorsements and other MDT messages for example the pharmacist and dietitian delivering key messages / headlines on their respective topics.
Both the online and DVD resources were developed with service user input. Previous service users and current CR patients were invited to attend focus groups and events were held to gain feedback and end user testing. Patient survey and feedback was sought throughout the development process and into the operational phase of the programme.
Staff engagement with the proposed changes in service delivery was a key priority. Adoption of technology into clinical practice was initially met with apprehension and uncertainty. Motivational training and change management courses, using the Myers Briggs approach, were provided to all team members. Regular team meeting were held where progress was reported (including patient feedback). Team members involved in the development of the two workstreams were given time to participate and all staff development and training was internally funded.
A project awareness campaign was undertaken across the trust and with local commissioners once the new resources and services were launched. Data for web usage and healthcare utilisation are monitored on an on-going basis as are the number of completed cardiac risk factor assessments, CR assessments, drop-out rates and online evaluations.
Initial qualitative and quantitative data was analysed and a communications strategy was developed for dissemination of results including publication of academic papers, presentation at relevant scientific meetings, promotion with NHS Improvement and the local Cardiac Network.
Results and feedback have been overwhelmingly positive:
- More patients have progressing onto their individual assessment.
- More patients are accessing their CR programme via 'Activateyourheart' with positive feedback. 'I completed the activate your heart web based programme and it was brilliant for work circumstances and travelling' - Waiting times for patients accessing their educational component have reduced from 11 to 3 weeks.
- Patients have been offered more choice. When asked, 65% of people who completed 'Activateyourheart' said they would not have attended an out-patient CR programme.
- Staff time has been more effectively and efficiently used and over a four week period has released 15 hours band 6 CR professional time.
- Attendance at initial CR assessment improved from 44% to 57% with programme completion rates now at 73%. The cost savings of delivering this alternative form of rehabilitation can be considered from two angles:
- The current cost of 'Activateyourheart' programme is in the region of £330 including initial first patient assessment and exit/final patient assessment. This compares with £700 for a conventional approach.
- A secondary cost saving opportunity is associated with the reduced cost associated with readmissions. Local data suggests that readmissions rates are reduced by 50% by participating in a programme of CR. If more patients access their CR programme in a timely manner this potentially reduces readmissions to the trust.
The new approach to delivering education much earlier will ensure that patients are better informed about their cardiac condition and how to cope. Using patient testimonials and consultant endorsements will positively encourage patients to attend their CR assessments and subsequent programme tailored to their needs and ability. 'Activateyourheart' is now well established and embedded within existing range of options available to our patients.
Further development to enhance the website is planned to incorporate content for heart failure patients. The early education component continues to be provided 2-3 weeks post discharge with ongoing monitoring of uptake, patient feedback and associated readmission data.
Key learning points
Factors for success:
- Listening to and involving patients and service users in the initial scoping, design and implementation phases allowed the service to be developed in response to their needs and expectations.
- Involving and investing in staff throughout the planning and development of the project has enabled engagement across the team and a successful change in service model.
- Getting consultants engaged, whilst sometimes challenging was key to successful delivery.
- Communication is key to success. Regular formal and informal meetings were held to ensure all stakeholders were able to contribute and learn about progress.
- A positive 'lessons learned' approach was taken regarding issues or challenges with the team.