BACR Standards: A Useful Tool? Jennifer George / Michelle Bull SWL Cardiac and Stroke Network

Overview 1.Background 2. Our work before the standards 3. How we have used the standards 4. Some Issues 5. Conclusion

Networks “Should come together to form local networks of cardiac care, agreeing detailed locally relevant referral criteria and care pathways” CHD NSF (2000)

Networks The purpose of a network is to guide and support the services that comprise it and the people that use them. The purpose of a network is to guide and support the services that comprise it and the people that use them. Organisations join networks because they can do what they need to more effectively together than if they operate alone. Organisations join networks because they can do what they need to more effectively together than if they operate alone. National Stroke Strategy 2007

South West London Tertiary Centre 7 programmes 1 Tertiary Centre 4 DGHs 2 Community Hospitals Task group

Work before the standards Baseline Assessment Aim: To create an accurate picture of CR provision To create an accurate picture of CR provision To identify any gaps in the current service across SWL To identify any gaps in the current service across SWL To use information to determine a work programme for the task group. To use information to determine a work programme for the task group. Method: All 7 programmes completed the assessment which was designed against Chapter 7 of the NSF.

Baseline Assessment Outcomes: Staffing levels, team make-up and funding were variable and did not appear to be based on need. Staffing levels, team make-up and funding were variable and did not appear to be based on need. All programmes had a waiting list. All programmes had a waiting list. Current data systems did not allow for assessment against NSF goal of 85% of people with diagnosis of AMI or revasc being offered cardiac rehabilitation. Current data systems did not allow for assessment against NSF goal of 85% of people with diagnosis of AMI or revasc being offered cardiac rehabilitation. Next steps: An audit to gain an understanding of patient numbers and patient movement through each programme.

Work before the standards Retrospective Audit Aim: Justification of service e.g., referral numbers. Justification of service e.g., referral numbers. Patient flow and movement through programme e.g., identify specifics of where they drop out & why. Patient flow and movement through programme e.g., identify specifics of where they drop out & why. Benchmarking Benchmarking Method: One years worth of data One years worth of data Patients with either a diagnosis of MI or after Coronary Artery Bypass Graft, PCI or other intervention (e.g., valve) were included in line with the NSF. Patients with either a diagnosis of MI or after Coronary Artery Bypass Graft, PCI or other intervention (e.g., valve) were included in line with the NSF. Hospital admission data was requested from IT departments Hospital admission data was requested from IT departments Data was collected manually by pulling individual patient files. Data was collected manually by pulling individual patient files.

Assessment & Audit Outcomes Each programme provided different services to patients, leading to inequity of provision and making comparison across the sector difficult Each programme provided different services to patients, leading to inequity of provision and making comparison across the sector difficult Agreed there was a need for core elements that a rehab service should include (in line with NSF standards and latest evidence) Agreed there was a need for core elements that a rehab service should include (in line with NSF standards and latest evidence) Endorsement of the BACR standards Endorsement of the BACR standards

The Standards A Co-ordinator who has overall responsibility for the CR service A CR core team of professionally qualified staff with appropriate skills and competences to deliver the service A standardised assessment of individual patient needs Referral and access for targeted population Registration and submission to the NACR A CR budget appropriate to meet the full service costs

The Core Components Lifestyle Physical activity and exercise: Diet and weight management: Smoking cessation: Education Risk factor management Psychological status and quality of life Cardio protective drug therapy and implantable devices Long-term management strategy

1. A Co-ordinator who has overall responsibility for the CR service  2. A CR core team of professionally qualified staff with appropriate skills and competencies to deliver the service (included in core components section) 3. A standardised assessment of individual patient needs  4. Referral & access for targeted patient population; - Exertional angina  - ACS (unstable angina or NSTEMI or STEMI) following medical/surgical management  - Before & after revascularisation  - Following any stepwise alteration in CHD condition  - Other atherosclerotic disease e.g., peripheral arterial disease  - Stable HF & Cardiomyopathy  - Following implantable device interventions  5. Registration and submission to the National Audit for Cardiac Rehabilitation (NACR) database  6. A CR budget appropriate to meet the full service costs  1. Lifestyle I) Physical activity & exercise: CR should include; - Risk stratification & baseline assessment of physical activity status & exercise/functional capacity  - Prescription  - Staffing levels & state the hours of work; Specialist Nurse  Specialist Physio  Dietician  Pharmacist  Clinical Psychologist Audit & Clerical  How we used the Standards? Assessment tool -

Findings Prog 1Prog 2Prog 3Prog 4Prog 5Prog 6Prog 7 Standard 1 (co-ordinator) Standard 2 (team) Standard 3 (assessment) Standard 4 (pt groups) Standard 5 (NACR) Standard 6 (Budget)  Not meeting the standard  Partially meeting the standard  Totally meeting the standard

What we did with results Sector wide Sector wide Quality assurance role Quality assurance role NACR NACR Agreed ideal pathway Agreed ideal pathway Increased profile for cardiac rehab Increased profile for cardiac rehab Individual Programmes Individual Programmes Development of new services Development of new services Supporting programmes through change Supporting programmes through change

Standard Exertional angina ACS Before & after revasc Following stepwise alteration Other Atheroscle oticdisease Stable HF & Cardio- myopathy Following Implantable e devices

Programme 2 Standard 4 - ICD pilot Standard 4 - ICD pilot Standard 2 - Business case development for heart failure Standard 2 - Business case development for heart failure Clinical lead Specialist Nurse PhysioDieticianPharmacist Clinical Psyc Audit & Clerical

Programme 2 Standard 2 – core team development Standard 2 – core team development Regular physiotherapy input Regular physiotherapy input Clinical lead Specialist Nurse PhysioDieticianPharmacist Clinical Psyc Audit & Clerical

How we used the standards Prog 1Prog 2Prog 3Prog 4Prog 5Prog 6Prog 7 Standard 1 (co-ordinator) Standard 2 (team) Standard 3 (assessment) Standard 4 (pt groups) Standard 5 (NACR) Standard 6 (Budget)  Not meeting the standard  Partially meeting the standard  Totally meeting the standard

Programme 5 Standard 5 – web based NACR pilot Standard 5 – web based NACR pilot Standard 4 - PCT secured funding to develop local community based programme Standard 4 - PCT secured funding to develop local community based programme Standard 2 - Appropriate staffing levels Standard 2 - Appropriate staffing levels Able to advise re appropriate model Able to advise re appropriate model

How we used the standards Prog 1Prog 2Prog 3Prog 4Prog 5Prog 6Prog 7 Standard 1 (co-ordinator) Standard 2 (team) Standard 3 (assessment) Standard 4 (pt groups) Standard 5 (NACR) Standard 6 (Budget)  Not meeting the standard  Partially meeting the standard  Totally meeting the standard

Programmes 3 and 4 Local programme resourced by staff from PCT and acute trust Local programme resourced by staff from PCT and acute trust Plans to move phase 3 to community as part of review of CNS roles Plans to move phase 3 to community as part of review of CNS roles Conflict between providers and commissioners Conflict between providers and commissioners

Programmes 3 and 4 Core Components Core Components Process mapping Process mapping Peer review Peer review Links with other services Links with other services Phase 4 mapping Phase 4 mapping Standard 2 Standard 2 Skills assessment Skills assessment

Where the standards have caused debate Definitions Definitions ACS ACS Cardio protective drug therapy Cardio protective drug therapy Staffing levels Staffing levels Budget Budget Commissioning Commissioning Annual review Annual review Who will assess this Who will assess this “Programme under development” “Programme under development”

Are they a useful tool? Yes Yes Useful driver to support development work Useful driver to support development work Support for programmes undergoing change Support for programmes undergoing change Informing commissioning Informing commissioning

But ……. Need to have strategic commitment at local level Need to have strategic commitment at local level Need higher national profile Need higher national profile Need agreement re “enforcement” Need agreement re “enforcement”

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