Cambridgeshire and Peterborough
Personalised Care Case Finding Programme
In partnership with Cambridgeshire & Peterborough ICB and
ECLIPSE (Equality of Care Led Insights for Patient Safety & Engagement)
Practice Pro-Forma
Project overview:
A high BMI is a significant and independent risk factor for the development and progression of cardiovascular disease, mediated through associations with hypertension, dyslipidaemia, and metabolic disorders such as type 2 diabetes. In England, an estimated 64% of adults are overweight, with an ongoing widening of the gap between the most and least deprived individuals.
This programme forms part of the wider “Your Healthier Future” initiative being offered to practices throughout Cambridgeshire & Peterborough ICB to support cardiovascular population health management. This programme will use the opportunity of large-scale patient engagement to collect updated patient health information for BMI and other factors such as ethnicity, language preference and lifestyle information.
Objectives
To ensure patients have an up-to-date weight on record (alongside additional health record information such as ethnicity, language preference, alcohol consumption and smoking status).
To facilitate onward signposting of appropriate patients to weight management and other lifestyle optimisation services.
Practice Patient Engagement – Activation of this programme will activate the BMI Detect pathway within Eclipse, providing a list of all eligible patients, alongside additional priority groups, which can be further filtered and prioritised by parameters such as levels of deprivation, ethnicity, comorbidities, and risk.
Eclipse Patient Engagement – will then automatically engage with these priority patient groups via the PEGASUS platform to inform, educate, counsel, and consent patients to complete their dynamic health questionnaire. The result will be captured within Eclipse, and through integration with the GP clinical system will code relevant information for the patient. A patient PDF report will be produced, recommending any further action or optimisation that should be considered in managing this patient. This can then be reviewed and implemented by the GP practice, as seen fit.
The solution being offered utilises Eclipse’s digital patient engagement platform which will automatically identify your eligible patients, engage with them via SMS, educate and counsel them using a lander page and consenting them via access to their secure questionnaire portal.
REMUNERATION:
This patient support programme is part of the Cambridgeshire & Peterborough Your Healthier Future programme. There will be some additional funding for practices participating in this programme. Practices have three choices:
Practice Patient Engagement - Practices that wish to activate Practice Patient Engagement to risk stratify and identify patients for the Personalised Care programme will undertake patient engagement, reviews, and follow-up through their own practice team. The payment is set at £1,000 if the target* is met.
Eclipse Patient Engagement - Practices that wish to activate Eclipse Complete will have all patient engagement handled by a centralised patient support hub. The payment is set at £400.
No participation - Practices that do not wish to utilise either Practice Patient Engagement or Eclipse Patient Engagement will not receive additional financial remuneration for this programme.
*Individual practice targets will be based on practice performance for each of the metrics being targeted in the Your Healthier Future programme. These targets have been approved by the ICB and require an equal effort from all practices within an upper and lower threshold.
EVALUATION: As well as quantitative data, which will be collected via Eclipse, patient reported outcomes and perceptions of the new pathway will be collected through patient questionnaires.
If your practice would like to take part: Please complete the below pro forma, expressing your interest and permissions for patient engagement. Please note that you will be notified prior to any active patient engagement, and your practice will be issued with a guide on how to view patient lists and document patient reviews.