2008-2011NHS FIFE KEEP WELLTHE JOURNEY SO FAR

Keep Well

Margaret Bell, Keep Well Manager

Countdown

6 100 1 100

9759

TIME UP 40

Countdown

100 x 100 = 10000

6 x 40 = 240

10000 – 240 – 1 = 9759

NHS Fife Timeline

Wave 2 of National Pilot Programme 2007

First Health Checks June 2008

Phase 1 – Mixed Model of Delivery from June 2008-December 2009

Phase 2 – Central Team delivery from January 2010-to date

Pharmacy Programme 2010-to date

Cohort

Age 40 – 64 living in SIMD 20% most deprived areas

Other Vulnerable populations

Scottish Index of Multiple Deprivation

Original cohort 17,272

Extension to age group, cohort today 25,836

NHS Fife Delivery Model

Central team of Keep Well staff employed by NHS Fife oversee, identify, engage and deliver health checks to the identified cohort and vulnerable populations.

Work from one centralised base

Peripatetic model of delivery in community venues

Service operates 8am-8pm over 7 days

Partnership with local GPs and a range of partner agencies

GP Partnership

Keep Well DB

SCI-DC Gatewa

y

GP SystemKeep Well

Information System (KWIS)

KW Health Check ‘Out and About’ form

KW Health Check ‘Out and About’ form

CHI Periodic spreadsheet

ISD and Local reporting

SIMD Periodic spreadsheet

KW Health Check

EXISTING KEEPWELL INFORMATION PATHWAY

Keep Well DB

SCI-DC Gatewa

y

GP SystemKeep Well

Information System (KWIS)

KW Health Check ‘Out and About’ form

KW Health Check ‘Out and About’ form

CHI Periodic spreadsheet

ISD and Local reporting

SIMD Periodic spreadsheet

KW Health Check

EXISTING KEEPWELL INFORMATION PATHWAYMAINSTREAM KEEPWELL INFORMATION PATHWAYCHI24

Nightly Update

Electronic Data

Capture on laptop

Cohort Reached

Since June 2008 :

Keep Well has attempted to contact 22,631 patients

Via 47,498 contacts

29% (n=13,579) successful reach

22% (n=10,556) appointed

21% (n=9,759) attended (includes 444 patients without tracking data)

Successful Contacts

Clinical Measurements

Mean Assign score = 16% Assign score 20 or greater = 28%Mean Cholesterol measurement = 5.2 mmol/l% Cholesterol over 5 mmol/l = 54%Mean BMI = 29% BMI in obese categories 37%Mean systolic blood pressure (BP) = 135

mm/hg% systolic BP greater than 140 mm/hg = 33%

Clinical Outcomes

Referral to services (excl. General Practice) = 14%

Clinical Outcomes

12% of (n=770/6438) patients added to one or more disease registers post health check

Lipid Regulating Drugs

Evaluation Overview

Summary

Full evaluation report is available

A 12 month follow up evaluation is currently underway. Report will be available December 2011

Contact:Clare Robinson clarerobinson@nhs.net Department of PsychologyStratheden HospitalCupar Fife KY15 5RRTel :01334 696336

Countdown

I R A N T R P S E P HP A R T N E R S H I P

Contact Details

Margaret Bell Keep Well ManagerLynebank HospitalDunfermlineFife KY11 4UW

Tel: 01383 565136Email: Margaretbell3@nhs.net