ࡱ> 1 dbjbj 8ЅqhЅqh[* * 8t|CXX([N$gCiCiCiCiCiCiC$F8I&C '[[ ' 'CC*** 'FgC* 'gC**ABWgP'ASCC0CA^J(^J,B^JB( "*#<$;CC)C ' ' ' '^J* X :  Document history The source of the document will be found in:- Revision History RevisionRevision dateSummary of changesChange AuthorChanges markedDraft Version 1.120/02/09Amendments to reflect current service provisionJanet LittleDraft Version 1.216/04/09Updated with additional information HPAJanet LittleDraft Version 1.306/05/09Amendments following comments from Cardiac Liaison Specialist PractitionerJanet LittleDraft Version 1.412/05/09Changes following consistency checkJanet LittleDraft Version 1.5 20/05/09Amendments following comments from Engagement DirectorateJanet LittleDraft Version 1.624/06/09Amendments Following comments from DHFTJanet LittleVersion 1.720/8/09Revision to effective period.Liz Ryalls Approvals This document requires the following approvals NameSignatureJob titleDate of issueVersionDianne PrescottDirector of Service Improvement DHFTTrish ThompsonDirector of Community and Primary Care Commissioning  Distribution -This document has been distributed to: NameJob TitleDate of issueVersionJo SillsLong term Conditions Manager, Derby City Provider Services16/04/09 06/05/09Draft Version 1.2/1.3Carol GrocottSpecialist Practitioner, Cardiac Liaison16/04/09 06/05/09Draft Version 1.2/1.3Sue SimsAD for Acute and Primary Care Commissioning12/05/09Draft Version 1.4Val WinnCommissioning Manager12/05/09Draft Version 1.4Gill CollinsonDirector of Engagement12/05/09Draft Version 1.4 PBC GroupsPBC Managers12/05/09Draft Version 1.4Liz RyallsAD Provider Services Commissioning20/05/09Draft Version 1.5NHS Derby City/ DHFT Contract Delivery Group SERVICE SPECIFICATION ServiceCardiac Liaison ServiceCommissioner LeadJanet LittleProvider LeadJo SillsPeriodNo end date, but amendments to this specification are expected within 1 year due to review of the cardiac rehabilitation pathway and subsequent revision to the service specification. 1. Purpose  1.1 Aims To provide all patients discharged from hospital with a diagnosis of STEMI or NSTEMI (acute myocardial infarction) and acute coronary syndrome (ACS) with timely support, advice and an individualised care management plan. This is referred to as Phase II in the four-phased cardiac rehabilitation pathway as defined in Chapter 7 of the National Service Framework for Coronary Heart Disease (DoH 2000). The service delivers expert, evidence-based clinical and psychological care to all qualifying patients registered with an NHS Derby City GP (including their relatives and carers) in the early post hospital discharge period. In summary, the Community Cardiac Liaison specialist nurse helps patients to: Change poor health habits Regain confidence Recover psychologically Deal with social issues Devise long-term self-management plan and goals Live longer. (British Heart Foundation (BHF) 2007) 1.2 Evidence Base Coronary heart disease (CHD) is the most common cause of premature deaths in the United Kingdom (UK). Approximately 19% in men and 10% in women; CHD caused approximately 31,000 premature deaths in the UK in 2006 (BHF 2007). Death rates have been decreasing in the UK since the late 1970s, although they continue to be the highest in Western Europe. However, whilst mortality from heart disease is decreasing the amount of morbidity associated with heart and circulatory disease is not. Evidence suggests cardiac rehabilitation (CR) results in improving peoples ability to work, their physical capacity and their perceived quality of life. Currently, nearly 3 million people in the UK are living with the burden of heart disease, the countrys biggest killer. Rehabilitation can save lives and improve quality of life, enabling patients to escape the fear and isolation that being diagnosed with heart disease or suffering a heart attack can bring (BHF 2008). The Community Cardiac Liaison Service aims to ensure high quality Phase II CR is available to all NHS Southern Derbyshire CCG (Derby City localities) patients who can derive benefit from it. Some trials demonstrate links between cardiac rehabilitation, psychological interventions (such as patient education), counselling and cognitive-behavioural interventions for lifestyle changes with a reduction in major risk factors including blood pressure and cholesterol levels, and an increase in patient knowledge and psychological well being. Resulting in improved lifestyle, reduced hospital re-admissions and improved return to work rates (Linden, Stossel and Maurice 1996; Mullen, Mains and Velez 1992; NICE 2007). In the early post discharge period, many patients feel isolated and insecure. It is recognised that anxiety levels are high in patients following discharge from hospital and may mean that they are too afraid to make the necessary lifestyle changes that will assist their progress and recovery and facilitate a reduction in the chances of a further cardiac event. Some studies suggest that a home visit creates a more relaxed environment and allows the patient to feel more comfortable to express their feelings and raise questions and concerns, whilst recognising the increased influence of the partner/carer within their own home (Fisher 1997). 1.3 General Overview The service is a community based NHS Derby City specialist facility that provides pro-active advice and support tailored to the needs of each patient based on a comprehensive holistic assessment of their cardiac risks and in consideration of their environment. The service has traditionally been delivered as part of Southern Derbyshire cardiac rehabilitation network, in liaison with Derbyshire County PCT equivalent nurses. The service consists of a specialist nurse who accepts referrals of appropriate patients from Derby Hospital Foundation Trust (DHFT) cardiac rehabilitation team on exit from Phase I discharge. Patients are contacted by telephone to give early support and advice, and also to arrange a face-to-face consultation to holistically assess and jointly develop a personalised care management plan. The initial contact determines if other services such as interpreter services also need to be present at the consultation. Details of the consultation are logged and the patients GP is informed, including Read coded data relevant to CHD registers. The specialist nurse may also refer patients to other health and related professionals where identified, with the necessary follow-up actions. The Community Cardiac Liaison Nurse acts as a resource for other community health professionals and is also involved in related staff training programmes/packages. Historically, the numbers of referrals by financial year are: Year: 2006/7 2007/8 2008/9 Referrals: 444 443 491 1.4 Objectives The Community Cardiac Liaison Service will provide support to all patients appropriately referred by DHFT (including their relatives, partners and carers) during Phase II of the cardiac rehabilitation pathway. Undertaking a comprehensive assessment of cardiac risk, including physical, psychological and social needs, including episode history and Phase I appraisal for cardiac rehabilitation. Help the patient to change poor health habits by giving pertinent advice to enhance their quality of life on such matters as smoking cessation, alcohol consumption, physical activity, dietary modification, etc. Increase the patients knowledge and understanding of their cardiac condition so as to regain their confidence, especially in relation to their social and vocational activities. Undertake a medication review and educate about effective use, benefits and harms. Report any irregularities. Jointly develop and agree an individual plan for meeting rehabilitation needs and promote self-management skills. Help to deal with social issues that impede psychological recovery, such as driving, travel, benefits, etc. Provide timely and relevant information to GP and refer onwards to other care professionals as necessary. Help to dissipate anxiety and depression by dealing with patients urgent pressing issues. Provide an overview of the cardiac services and options available to the patient, including the promotion of Phase III physical activities. Provide supporting literature in the patients language. Perform as a specialist for primary health care in relation to cardiac rehabilitation. In summary, cardiac rehabilitation promotes recovery, reduces disability and prevents further illness; it helps patients live longer. 1.5 Expected Outcomes 100% of consenting patients referred to the service by DHFT will be contacted in the early post-discharge period (within 4 working days wherever possible). 100% of consenting patients warranted by triage or those patients requesting one will be offered a face-to-face consultation. 100% of consenting patients contacted will be given appropriate support. 100% of consenting patients contacted will be offered advice, including promotion of Phase III cardiac rehabilitation. 100% of patients referred to the service will be recorded in a database and letter sent to their GP informing them of advice/support given. The ultimate outcome therefore is maximised patient independence, improved quality of life, improved lifestyle and a reduction in the risk of secondary cardiac events with the associated reduction in hospital re-admissions. (Identification of patients who do not consent to inclusion in Phase II of the cardiac rehabilitation programme will be made prior to discharge from Phase I and noted in the patients records)  2. Scope  2.1 Service Description The Community Cardiac Liaison Service works to advanced competency level. The Specialist nurse responds, assesses and evaluates the condition and delivers appropriate care to patients diagnosed with STEMI, NSTEMI, or ACS who are registered with a NHS Southern Derbyshire CCG (Derby City localities)GP. The Community Cardiac Liaison Service provides support and advice to patients and their relatives and carers in the early post hospital discharge period. The service is located in the community and provides an axis from which to signpost and coordinate patients to other services that have the potential to result in lifestyle changes and subsequently reduce risks of further cardiac events. 2.2 Accessibility/acceptability All patients in the post hospital discharge period following a diagnosis of STEMI, NSTEMI, or ACS registered with a NHS Southern Derbyshire CCG (Derby City localities)GP. 2.3 Whole System Relationships In order to support seamless service provision the service has close working relationships with: DHFT Cardiac Rehabilitation team Nursing and management colleagues in community and hospital settings General Practice 2.4 Interdependencies Interdependencies exist with: - General practice Advice to primary health care team Interpreting services as required Social Services 2.5 Relevant networks and screening programmes Whilst not truly a network or screening programme the cardiac liaison service is an integral element of cardiac rehabilitation being Phase ll of a four Phase programme. 2.6 Sub-contractors None  3. Service Delivery  3.1 Service model The Community Cardiac Liaison nursing service is delivered as part of a multidisciplinary programme of secondary prevention and cardiac rehabilitation as specified in the National Service Framework for Coronary Heart Disease (NSF for CHD) (DoH 2000). Community Cardiac Liaison specialist nurses are core members of the four-phased cardiac rehabilitation multi-disciplinary team, with specific responsibility for Phase 2 the immediate post discharge period. Procedures are carried out in accordance with the Southern Derbyshire protocol for the Community Cardiac Liaison Service (Grocott & Roscoe 2008). Community Cardiac Liaison nurses provide an individualised care management plan in the immediate post discharge period. Community Cardiac Liaison nurses may also be called on by patients, nursing, medical, or other health professionals to follow-up specific patients after the Phase 2 period. The service is delivered in accordance with Standard 12 of the NSF for CHD (DoH 2000); and NICE clinical guideline 48 (NICE 2007) and British Association of Cardiac Rehabilitation standards (BACR 2007). Community Cardiac Liaison specialist nurses will have a first level registration with a post-registration specialist qualification or relevant first degree as a minimum. Community Cardiac Liaison nurses also require relevant teaching and motivational skills to educate patients and health professionals. The Community Cardiac Liaison service is supported by secretarial and administrative support to ensure efficient operation of the clinical service. 3.2 Care Pathways Community Cardiac Liaison is delivered as part of the four-phased cardiac rehabilitation programme.   4. Referral, Access and Acceptance Criteria  Geographic coverage/boundaries The service is available to all NHS Southern Derbyshire CCG (Derby City localities) GP registered patients discharged from an Acute Hospital with a diagnosis of STEMI or NSTEMI (Myocardial Infarction), Acute Coronary Syndrome (ACS) and those with a subsequent coronary angioplasty intervention. Location(s) of Service Delivery In the first instance, contact is made by telephone within 4 days of discharge to carry out an initial assessment and offer advice. Depending upon the outcome of the first contact, the Community Cardiac Liaison specialist nurse will consult patients in dedicated community clinics or visit them at home, as appropriate to their individual needs, and to include family/partner/carer when possible. The Community clinics take place in NHS Southern Derbyshire CCG (Derby City localities) premises. Days/Hours of operation The service is available Monday to Friday 08:30 16:30 excluding Public Holidays and weekends. Outside these hours there is a message taking service. Referral criteria & sources All NHS Southern Derbyshire CCG (Derby City localities) GP registered patients discharged from an Acute Hospital with a diagnosis of STEMI, NSTEMI, ACS, Chronic Stable Angina, or subsequent coronary angioplasty intervention. Exceptionally, referrals are accepted from DHFT for visitors who are temporarily staying with relatives in Derby City. These primary referrals are made by DHFT Cardiac Rehabilitation team irrespective of the discharging hospital. Secondary referrals for existing patients after the Phase 2 period are made by telephone or letter to the Community Cardiac Liaison specialist nurse from a variety of health professionals or direct from the patient or their carer. Referral route Primary referrals are made by facsimile/e-mail and secondary referrals are made by telephone, letter or e-mail to the Community Cardiac Liaison nurse. Exclusion criteria Patients not registered with a NHS Southern Derbyshire CCG (Derby City localities) GP or Southern Derbyshire CCG (Derby City localities) Post Code, or with a diagnosis of Heart Failure, or post-surgical patients (coronary artery bypass grafting, valve repair/replacement, ICD) Response time & detail and prioritisation All patients to receive first contact telephone call within four working days of discharge or referral, whichever is the latter. All patients to be offered a home visit or clinic appointment to take place within ten working days of discharge. All referrals (primary and secondary) are prioritised according to patients clinical need. Equity issues (EIRA) It is the responsibility of the Provider to actively meet the requirement s of the Equality Duties (Race, Disability and Gender) these include: - Eliminating discrimination Promoting equality to services and of employment opportunity Ensuring effective data capturing and analysis of service provision Conducting Equality Impact Risk assessments (ERAs) on policies, procedures and services Equality Impact Risk Assessment (EIRA) must be undertaken and documented as part of any service review process or if any change is made to the provision of the service which could impact on those in receipt of the service. Staff employed by this service will recognise and respect the religious, cultural and social backgrounds of service users in accordance with legislation and local and national good practice The service will ensure that it has access to appropriate translation services/resources to enable equity of access and understanding.  5. Discharge Criteria & Planning  Patients will normally be discharged from the Community Cardiac Liaison service approximately 6 to 10 weeks after their discharge from hospital depending on their acceptance of, or eligibility for, Phase 3 rehabilitation. All clients are informed of the duration of the service and the availability of other services after the Phase 2 period. Patients who receive a home visit or clinic appointment will be given an individual care management plan. However, patients may self-discharge at any time during the Phase 2 period. Secondary referrals are event driven and dealt with on a case-by-case basis. Based on historical data it is estimated these numbers may increase by approximately 3% annually.  6. Self-Care and Patient and Carer Information  The cardiac liaison service aims to support and advice patients, relative and carers in the early post hospital discharge period in order to allay some of their fears and insecurities. One element of the advice provided is to encourage lifestyle changes and signpost to appropriate services, including cardiac rehabilitation, in an attempt to reduce the risk of further cardiac events. Patient information may be given by: Literature in the appropriate format and language Through telephone advice Through face to face contact  7. Quality and Performance Standards Quality Performance IndicatorThresholdMethod of measurementConsequence of breachReport DueInfection ControlCompliance with infection prevention and control standards relevant to the serviceAs per quality schedule.As per quality schedule.As per quality schedule.Service User Experience At least 50% return rate for surveys issuedRegular service user and carer surveys in formats appropriate to the preferences/needs of the client groupReport on actions taken to improve ways of obtaining feedback on user experience On requestImproving Service Users & Carers Experience The service can demonstrate actions and improvements made in response to user and carer feedback Improvement plans, report on actions taken and further surveysReport on actions taken to improve systems to respond to user feedback. On requestUnplanned admissionsEstablish baseline of patients readmitted to hospital with coronary related events in the early post discharge periodAudit the number of patients readmitted with further coronary related events in the early post discharge period and specific reasons for admissionImprovement plan focused on those events where possible actions of the cardiac liaison service could have prevented admission Annually and on request to inform service review processReducing Inequalities Evidence of inequity through E&D profile of patients accessing service compared with expected E&D profile of specific cardiac groupEIRAs for all elements of service Staff training records Equity of access demonstrated through access dataImprovement plan to Contract Delivery GroupAnnuallyReducing BarriersImproving ProductivityTo be addressed as part of the cardiac rehabilitation reviewAccess All new patients have an initial response within 14 working days of discharge by phone or home visit AuditImprovement planQuarterlyCare ManagementPatients have an individual management plan identifying the next stage of the cardiac rehabilitation pathway they will follow AuditImprovement planQuarterlyOutcomes90% patients have been contacted by the cardiac liaison service in the early post discharge period 90% of patients have details of how to access support and advice to help them make the required lifestyle changesAudit data Patient surveysImprovement plan to Contract Delivery GroupAnnually and on request to inform service review processAdditional Measures for Block Contracts:-Staff turnover rates Sickness levels Agency and bank spend Contacts per FTE   8. Activity Activity Performance IndicatorsThresholdMethod of measurementConsequence of breachReport DueContactsAll patients contacted following referralNumber and type of contacts e.g. home visit, telephone consultation, to include age and ethnicityImprovement planAnnuallyActivity Plan  9. Continual Service Improvement Plan  The service must ensure that they contribute to the wider patient safety agenda including, but not exclusively, the control of infection agenda and the identification, reporting and investigation of incidents and complaints. Participation in clinical audit and implementation of changes arising from audits should take place, in accordance with the organisations audit plan. The service should be able to demonstrate learning and improvement across the quality agenda and in response to local and/or national policy guidance.  10. Prices & Costs  10.1 Price Basis of Contract Unit of Measurement Price Thresholds Expected Annual Contract Value Block/cost &volume/cost per case/Other________* Total *delete as appropriate 10.2 Cost of Service by commissionerTotal Cost of ServiceCo-ordinating PCT TotalAssociate PCT TotalAssociate PCT TotalAssociate PCT TotalTotal Annual Expected Cost     References BACR (2007) Standards and core components for Cardiac Rehabilitation. University of York: British Association for Cardiac Rehabilitation/British Cardiovascular Society BHF (2007) Coronary Heart Disease Statistics London: British Heart Foundation BHF (2008) Cardiac Rehabilitation...recovery or by-pass? National Campaign for Cardiac Rehabilitation London: British Heart Foundation DoH (2000) National Service Framework for Coronary Heart Disease Chapter 7, Cardiac Rehabiltation London: Department of Health Fisher, S. (1997) Development of a community cardiac liaison nurse service British Journal of Community Health Nursing 2: (4) Grocott, C.A., Roscoe, D. (2008) Southern Derbyshire Community Cardiac Liaison Service Protocol Derby City Primary Care Trust; Derbyshire County Primary Care Trust Linden, W., Stossel, C. & Maurice, J. (1996) Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Inter Med pp. 745-752. Vol. 156 Mullen, P.P., Mains, D.A. & Velez, R. (1992) A meta-analysis of controlled trials of cardiac patient education. Patient Education Couns. Pp. 143-162 Vol. 19 NICE (2007) Post Myocardial Infarction: Secondary prevention in Primary and secondary care for patients following a myocardial infarction London: National Institute for Health and Clinical Excellence     NHS Standard Contract for Community Services Schedule 2 Part 1 Gateway Reference 10804 Page  PAGE 5 of  NUMPAGES 13 GHYZcq   ? 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