Denise%20Lewis%20Cardiac%20Rehabilitation%20Service%20Co-ordinator

1
Denise LewisCardiac Rehabilitation Service
Co-ordinator
2
WALES

3
Ceredigion and Mid Wales NHS Trust
4
Population

• Ceredigion 75,000
• Catchment population 121,000
• Plus holiday-makers and students

5
Background Summary

• 1996
• 25,000 pump priming BHF 2 year grant
• Employed IWTE C.R. Nurse
• In Kind services by dietician, pharmacist,
  physiotherapist, cardiac nurse.
• Full funding for C.R. Nurse when grant money
  ended

6
Back ground to the Present Service

• In Nov 2003 a Big Lottery Fund award of 289,572
  allowed the development, implementation and
  evaluation of the Ceredigion Communities Cardiac
  Rehabilitation Scheme.
• Previously the supervised exercise element was
  only available at Bronglais hospital, once
  weekly, and only for patients recovering for a
  Myocardial Infarction (M.I) living within the
  Aberystwyth area.

7
How Did We Do It?Partnership Bidding
Ceredigion health alliance
8
Geophysical Problems

• Geographically remote sparse, rural, isolated
  population
• Deprived areas
• Poor public transport links
• Growing Elderly population
• rural deprivation can be difficult to
  recognise as it often exists in isolated pockets
  and, because most statistical measures fail to
  take account of spatial factors which are a
  feature of rural deprivation, it is difficult to
  illustrate statistically. Dyfed Powys Public
  Health Annual Report 2002

9
Previous service INADEQUATE

• Poor access to services
• 1 whole time equivalent CR Nurse post hospital
  based
• 1 exercise session per week, in physiotherapy
  dept at BGH hospital ,for 8 weeks.

10
The Cardiac Rehabilitation Annual Report of 2000
stated that

• Of those patients admitted to hospital with a
  primary diagnosis of M.I only 40 of those
  eligible attended hospital based Cardiac
  Rehabilitation..
• Patient reasons for non attendance
• distance to hospital (for most this would mean a
  round trip
• 60 miles)
• local transport is inconvenient and
  inaccessible
• inability to drive due to cardiac condition
• 4 hrs away from employment

11
Patient service questionnaire for Cardiac
Rehabilitation 2000

• Reported that
• Readmission rates following M.I. had fallen from
  23 ? 8.3
• Smoking cessation had risen from 68.1 to 91
• 92.3 attributed there recovery to the Cardiac
  Rehabilitation Specialist Nurse
• Compliance by patients has significantly risen in
• cholesterol management,
• medication compliance
• healthy eating
• exercise
• and weight loss

12
Aims - in Real Language

• To show people how much fun exercise can be
• To have a good laugh
• To keep them out of hospital
• To find out if what we do makes a difference
• To find out if we are doing a good job
• To find out what we need to improve on

13
Aims - in Real Language

• To help people through the rough times when they
  have had bad news about their condition and get
  them back on track
• To explain all the double Dutch jargon provided
  by medics/cardiologists , ETC

14
Aims - in Real Language

• To be that shoulder to cry on
• To teach them all about different ways to keep
  healthy
• To try and stop them from having another cardiac
  event

15
Aims in Real Language

• Help them to cope with having a heart problem
• To help them make new friends
• To always have any open door should they need it
• To teach them how to get the most from life and
  live longer

16
In Sales Talk What Was Actually Said

• To promote the benefits of a healthy life style
  of participants and their families
• To Promote social integration and reduce social
  isolation through the provision of community
  based cardiac rehabilitation
• To promote a non threatening, non institutional
  approach to health promotion

17
Cont..

• To provide a research based cardiac
  rehabilitation service that is accessible for
  those residents of Ceredigion with established
  CHD
• To provide and promote a safe and effective,
  approved programme.
• To establish a multi disciplinary approach to
  health care

18
What Did We Need?

• Evidence of Need - audit, annual reporting ,the
  bigger picture, link in with other organisations
• Enthusiasm - be positive
• Guts - dont be afraid to ask for help
• Determination- ask yourself how much you really
  want it. If you dont truly believe in what you
  are saying no one else will

19
What Dont You Need?

• A negative attitude - nobody likes a whiner
• A false perception that lots of people will want
  to help you
• A false perception of how time consuming it is
  a good quality report requires time investment

20
Monitoring/Evaluation

• In partnership with the Sports and Exercise
  Science Department, University of Wales,
  Aberystwyth. PHD Student
• Data collection mechanisms include
• Participant throughput numbers
• Physiological/psychological pre- and post-testing
• Follow up evaluation questionnaires/focus group
  meetings
• Reduction of further cardiac events
  retrospective study of readmissions
• Audit data collected from risk factor management
  tool
• Feedback sessions for staff,participants involved

21
The results below indicate the trend of the
direction of change pre classes to post classes,
post classes to 6 month follow up and the overall
trend of the score
Measure Direction of change pre classes to post classes Direction of change post classes to 6 month follow-up Overall direction of change Desired direction of change for improved health
Health related quality of life ? ? ? ?
Self-rated health ? ? ? ?
Anxiety ? ? ? ?
Depression ? ? ? ?
Life Satisfaction ? ? ? ?
Physical self-worth ? ? ? ?
Global self-worth ? ? ? ?
Habitual physical activity ? ? ? ?
Motivation ? ? ? ?

22
Measure Direction of change pre classes to post classes Direction of change post classes to 6 month follow-up Overall direction of change Desired direction of change for improved health
Hip circumference ? ? ? ?
Waist Circumference ? ? ? ?
Weight ? ? ? ?
Skinfold measurements ? ? ? ?
Autonomy ? ? ? ?
Competence ? ? ? ?
Relatedness ? ? ? ?
23
6 month Maintenance Usage12 Months

• Aberystwyth 840
• Aberaeron 88
• Cardigan 376
• Lampeter 639
• Total Usage 1374
• Only gym use.
• Does not include swimming or circuits

24
Evaluation of Outcomes

• 503 patients were referred in 24 months
  indicating the level of demand.

25
Evaluation of Outcomes

• 74 of referrals started classes indicating
  attractiveness. 69 of patients completed
  treatment (national average completion rates are
  50). Early exit was mainly due to ill-health.
  This ill-health was associated with the patients
  condition, not as a result of the scheme where
  there were no hospitalisations, resuscitations or
  deaths.

26
Evaluation of Outcomes

• The main source of referral was the hospitals. A
  variable rate of referral from different GP and
  health centres reflected different extent of
  engagement.

27
Evaluation of Outcomes

• The scheme utilised local authority leisure
  centres throughout the county demonstrating
  successful partnership work and the local
  community-base to the programme.
• Participant evaluation was very strong with
  around 90 reporting high satisfaction with the
  organisation, the staff, the exercise programme,
  and their own personal improvement in fitness,
  health and confidence

28
Evaluation of Outcomes

• The structure of the Scheme and the approach of
  the exercise leaders helped participants improve
  their feelings of confidence and independence.
  Social aspects of the approach were also
  important. These factors were considered
  important in achieving a high adherence and
  continuation rate.

29
Evaluation of Outcomes

• The comprehensive programme resulted in
  statistically significant improvement in
  health-related quality of life, self-worth,
  habitual physical activity, and exercise
  tolerance along with a significant reduction in
  anxiety, skin-folds and resting heart rate.

30
Evaluation of Outcomes

• Six-month follow-up after patients left the
  scheme showed a sustained impact. Of the
  follow-up sample of 121, 46 (80 of responders)
  were still exercising and demonstrated a
  sustained improvement in habitual physical
  activity, exercise tolerance and physical
  health-related quality of life.

31
How Do We Fit ?
32
National and Local Plans / Policy ?

• Improving Health in Wales A Plan for the NHS and
  its Partners. (National Assembly for Wales
  February 2001).
• Improving Health in Wales the Future of Primary
  Care A Consultation Document
• (National Assembly for Wales 2001)
• National Service Frameworks for CHD (2001)

33

• Designed for Life Creating World Class Health
  and Social Care for Wales in the 21st Century
• (National Assembly for Wales May 2005)

34
Ceredigion Health Social Care and Well Being
Strategy 2005-8

• Major Risks to health and social well being
  include
• Ischaemic heart Disease
• Unhealthy diet
• Lack of exercise
• Smoking
• Obesity
• Substance and alcohol abuse
• Poor geographical access to services
• depression

35

• Provide cardiac rehab specialist services
  accessible for all residents of Ceredigion with
  established CHD
• Providing cardiac rehabilitation scheme and
  access to long term facilities which are close to
  the patients home
• Working in partnership with other organisations
  Ceredigion county Council, Aberystwyth
  University Sports Science Dept, Primary Care

36

• Clear pathways of Cardiac Rehabilitation Care
• Including
• early assessment
• self management plans
• multi disciplinary approach to Cardiac Health
  and Well being
• Pro active participants - taking responsibility
• Chronic disease management of cardiac patients
• Reduction in crisis management of cardiac
  patients

37
An Evolving Community service?
38

• Participant Driven
• Supervised WOODLAND walks
• 16 Supervised exercise sessions per week
• Flexible to the needs of those with Chronic
  Disease

39
What have WE Gained

• Knowledge and experience of
• project management
• Working in partnership with other organisations
• Removing barriers to success
• Greater health gains
• Greater understanding of the research process
• A service which has been properly researched
  using validated physical /psychological tools
• The opportunity to
• show our vision was achievable and is successful
• improve our standards, develop protocols,
• Professionally develop
• Show capability to lead a project

40
IMPLICATIONSFROM APRIL 07 ?
41

• Complete withdrawal of service from ALL four
  leisure centres across the county, Lampeter,
  Aberystwyth, Cardigan, Aberaeron. No community
  based service.
• 1 WTE job share cardiac rehabilitation nurse-
  hospital based
• 1 exercise session per week- hospital based in
  physiotherapy dept BGH hospital.
• Inequality of service provision

42

• Ceredigion producing less confident, more
  dependant cardiac patients, with
• increased anxiety,
• decreased fitness
• who are more likely to generate avoidable
  admissions to secondary care and avoidable G.P
  visits.

43

• Potentially, cardiac rehabilitation has prevented
  this for 377 patients.
• The cost saving to secondary care, based on
  average days in hospital, would have been
  484,633.50 for 2 years.

44
Costings



Specialist CR Nurse 3,068
Specialist CR Exercise Instructor 1,768
Admin Assistant Admin Assistant 660
Travel 503
Admin Costs 485

Total 6,485
6mth cost 38,907

12 months 12 months 77,814

45
What Did the Commissioners SAY?
46
Videoconferencing

• Overcome some of the problems of rurality
• Improve time-management
• Currently for Machynlleth patients
• Planned roll out to Tywyn patients

47
Health of the Community

• All primary schools in Ceredigion using our
  bi-lingual workbook - Keep Your Heart Healthy
  (ages 7-11)

48
(No Transcript)
49
School Sports Tops

• Logo Keep Your Heart Healthy Be
  Active/Cadwch Eich Calon Yn Iach Byddwch
  Fywiog
• Visual message to raise awareness of the
  importance of activity in the prevention of CHD
• Money raised by patients local business and
  organisations

50
(No Transcript)
51
Who Are We

• Multi disciplinary group
• Term of reference
• Welsh C. R. Standards
• C.R chapter in the updated NSF CHD
• HAVE OUR OWN VOICE

52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
(No Transcript)
56
Food for thought

• And God populated the earth with broccoli and
  cauliflower and green spinach and yellow
  vegetables of all kinds, so man would live a long
  and happy life.
• But Satan created McDonalds and brought forth the
  double cheeseburger and Satan said to man You
  want fries with that? And man said Super size
  them!.
• And man gained pounds.

57

• And God said try fresh fruit salad". But Satan
  created ice cream and man gained pounds.
• And God said I have sent thee heart healthy
• vegetables". But Satan created a steak so big
  that it needed its own platter and man gained
  pounds and his cholesterol went through the
  roof..

58

• And God brought forth running shoes and a resolve
  to lose those extra pounds. But Satan created
  cable TV with remote control so man would not
  have to toil to change those channels. So man
  watched others exercise and gained pounds.
• And God brought forth the potato a vegetable low
  in fat in brimming with nutrition. But Satin
  created the deep fat fryer in which to plunge
  them..

59

• And Man clutched his remote control, and ate his
  potato chips swaddled in fat and cholesterol. It
  tasted so good, but man went into cardiac arrest
• And God sighed and created quadruple bypass
  surgery
• But.

60
Satan controlled the health care system Thank
you