Aim statement
Identify patients with a recorded high blood pressure (BP) of more than 180/120 and reduce by 25 per cent, over nine months.
Also, increase awareness of cardiovascular disease (CVD) and diabetes and provide health checks closer to home, in two specific postcode areas.
What we did
- Used Blood Pressure lists to conduct system searches to identify patients with a raised BP
- Work resulted in bringing the BP reading in target for 46 per cent of those who engaged
- 14 per cent required no further action, and 19 per cent are awaiting Home Blood Pressure Monitoring (HBPM)
- Used data from the heat map on Curator (the Greater Manchester intelligence health hub) to identify patients with poor outcomes from CVD
- Mapped local area postcodes
- Worked with PCN community steering group, which includes representatives from the Voluntary Community and Social Enterprise (VCSE) sector, local council, primary care, social care, and personalised care roles within the PCN
- Liaised with local supermarkets, churches and clubs to set up blood pressure clinics
How the proactive and personalised care programme helped
- Access to live, high-quality personalised data that allows us to target the right groups of patients
- Ability to analyse own data through Curator was refreshing and empowered us to target groups of the highest need
- Helped shift from solely practice-based data and an individual practice approach to a collective set of data and a neighbourhood approach
- Actively seek people with a health need, that they may not even be aware of
- Engaged in a way that is right for the patient, rather than what is best for us
- Learned a lot about our local neighbourhood
Next steps
We want to embed these methods to address the CVD/diabetes needs of our local people and adapt them so we can apply them to any health need, therefore delivering proactive and preventative care.
We have generated lots of ideas to take this forward on a larger scale, and will use our PCN nursing associate, social prescribers and PCN GP assistants to undertake targeted work such as holding clinics in alternative settings, signposting to holistic services, running regular data searches and building on community connections.
There’s also a podcast which focuses on proactive and personalised care and the work SWAN PCN did on dementia, as part of cohort one of the programme.
