Topic: QIPC

Heart failure in Australia

Heart Failure is both a costly and complex clinical syndrome that can lead to high hospital readmission rates and poor prognosis. According to ‘Snapshot of heart failure in Australia’, approximately 511,000 Australians are being affected by heart failure which attributes to 61,000 deaths per year.¹

Reference

1. Chen L BS, Keates AK, Stewart S. Snapshot of heart failure in Australia. Mary MacKillop Institute for Health Research. 2017.

 

Although there are improvements in patient care, heart failure patient mortality rates remain high, with poor prognosis. Only 50% of patients with heart failure are alive, 5 years after being diagnosed.

 

 

The primary reasons for poor prognosis are mostly due to:

• • late diagnosis 
  • inadequate disease management

• disconnected care

 

Early detection of heart failure and effective management allows patients to have a better and longer life and can lead to a reduction in potentially preventable hospitalisations for their chronic condition.

 

Why is Quality Improvement important?

General practitioners play an essential role in early detection, identifying and managing patients with heart failure. Continuously undertaking quality improvement activities enable the GP to;

• Identify patients who are at risk of developing heart failure
• Review the care of current patients with heart failure
• Achieve better health outcomes for heart failure patients 
• Reflect on practice processes for care for heart failure management and identify opportunities to improve workflow, policy, and procedures for future care

 

Tips and tricks for clinicians

The Quality Improvement in Primary Care program (QIPC) helps supports general practices in creating in house quality improvement activities. Utilising a Model of Improvement (MFI) and POLAR, the GP can identify high risk patients and recently diagnosed Heart failure patients to be recalled and reviewed.

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An example of identifying your diagnosed Heart Failure patients who are at high risk of hospitalisation in the coming 12 months in order to recall and review;

1. Log into POLAR
2. Navigate to Reports (top left-hand corner)
3. Choose the “Clinical summary report”

1. Click the tab “Clinical” then “Clinical indicators” from the dropdown box
2. From the green “Inclusion Filters” select “Diagnosis”, then “SNOMED” and type “Cardiovascular”
3. Click on “Risk” and under “HARP Risk” select “Urgent”
4. To view who these patients are, click “Patient list” (top right-hand corner), then ‘Export’ to an excel spreadsheet.

 

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NPS MedicineWise is collaborating with the National Heart Foundation of Australia and has many useful resources of Heart failure. These resources can also be used as a quality improvement activity to fulfill your PIP QI requirements.

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National Heart Foundation of Australia also has a Smart Heart Guideline App available for the clinicians to access heart failure guidelines. 

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 Refer to Health Pathways for clinical management and treatment options for different health conditions including up-to-date cardiovascular risk assessment and heart failure management information.

If you wish to find out more about Heart Failure or SWSPHN’s QIPC program, please email: HSIsupport@swsphn.com.au

Digital information can transform the quality and sustainability of health and care. Used effectively, it can help save lives, improve health and wellbeing and support a sustainable health system that delivers safe, high quality and effective health services for all Australians.

As you may know, SWSPHN plays an important role in supporting quality improvement (QI) in general practices across our region with strategies to embed QI systems, improve data quality, analyse the practice’s data and identify areas for improvement, assist with goal setting and improvement activities, provide progress reports and feedback.

 

This month we take a closer look at our Quality Improvment in Primary Care program

 

• How does the program work?
• What are the benefits of participation?
• Who is eligible to participate?
• What do participants have to say about the program?
• How do I learn more?

 

SWSPHN’s Quality Improvement in Primary Care (QIPC) program has continued to grow since it began more than three years ago with 245 practices from the 425 practices in South Western Sydney participating in the program.

The three aims of the QIPC program are: improving data quality; utilising practice data to improve patient care; and identifying potential business revenue for the practice.

A key component of the program is the collection of a practice’s deidentified dataset which is then used to create both a benchmark report and clinical area of focus reports for our practices. To find out more about data security

We currently have the following clinical area of focus reports, diabetes, chronic kidney disease, cardiovascular disease, COPD, asthma, depression, anxiety, bipolar and schizophrenia.

The QIPC program has three tiers that indicate the practice’s level of engagement in quality improvement – as engagement increases, practices move into higher tiers and receive different reports.

From the 245 QIPC participating practices – nine practices are participating in Tier 1 (data sharing only), 177 in Tier 2 (data quality) and 59 in Tier 3 (clinical focus).

QIPC reports are created monthly and delivered quarterly to all participating practices. The practice uses this report to identify an area they would like to work on and SWSPHN records this on a model for improvement (MFI) template. This MFI is then reviewed the following visit to track the practice’s progress and to re-identify a new focus area to target for the following quarter.

 

What are the benefits of participation?

Benefits include:

• 40 Category 1 RACGP and ACRRM points and for general practitioners participating in Tier 3
• Enhance data management to meet accreditation standards
• Improve patient care while identifying potential business revenue
• Establish sustainable systems and processes for the practice
• Links to referral pathways

 

Who is eligible to participate?

All practices in South Western Sydney are eligible to participate if they are a computerised practice and sign SWSPHN’s Data Sharing and License Agreement. To find out more about these requirements, contact your Practice Support Officer on 4632 3000.

 

What do participants have to say about the program?

Dr Indran Rajendra, Bundanoon: “The focus of the QIPC program is data cleansing, which I am a big advocate for. I believe once in the right frame of mind, improving database quality and completeness easily integrates into the daily use of your medical software. Once improved, the database becomes a jewel in your crown resulting in better health and financial outcomes for the practice. As this program has strong focus towards attaining clean data I can only highly recommend all practices, if eligible, to also participate.”

Dr Dilruni Pallewatta, Liverpool: “The QI program from PHN has immensely helped me to improve my data quality and patient management especially in regard to diabetes. I myself have learned a lot and greatly advise other practices to join this program.” 

To find out more about the QIPC program visit our webpage or contact your PSO on 4632 3000.

We are transitioning away from the clinical audit tool, Pen CS, to the new POLAR GP tool.

The switch to POLAR GP from 1 July 2020 aims to better support practices in understanding their patient cohort. It will provide meaningful analysis to identify gaps in patient care, track patient outcomes, build on areas of quality improvement and identify opportunities to improve practice revenue.

This data tool is also used to help practices qualify for the PIP QI incentive.

Some of the key benefits of the POLAR GP tool are:

• one install per practice
• remote access to the tool
• user friendliness
• live data
• advanced data mapping
• advanced filter options
• regular PIP QI reports for each practice
• new reports coming on board including a COVID-19 report.

POLAR GP will be 100 per cent subsidised by SWSPHN and there will be no direct or ongoing costs to the practice.

All general practices currently participating in the PIP QI have previously signed a Data Sharing and License Agreement with SWSPHN for the use of the previous PenCS tool. Due to the transition to POLAR GP, a new software vendor, a contract variation will need to be signed prior to the installation of your POLAR GP tool.

Your PHN representative will be in contact with your practice shortly to provide more information. If you have any concerns about making this transition, please do not hesitate to contact: HSIsupport@swsphn.com.au

If you wish to know more about POLAR GP, please visit: Polar; Outcome Health; our website.