Cambridge and Peterborough
Health Record & BMI Detect Programme
In partnership with Cambridge & 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 on 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.
Eclipse Detect – 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 Complete – 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:
Eclipse Detect - Practices that would like to activate Eclipse Detect to risk stratify and identify patients for BMI Detect, will undertake patient engagement, reviews, and follow-up through their own practice team. Payment to practice is set at £1,000 if the target* is met.
Eclipse Complete - Practices that would like to activate Eclipse Complete will have all patient engagement undertaken for them through a centralised patient support hub. Payment to practice is set at £400.
No participation - Practices that would not like to utilise either Eclipse Detect or Complete will not receive any additional financial remuneration for the BMI Detect 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.