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. Additional complications include cancer (breast, colon and endometrial), arthritis and fatty liver disease. An up-to-date weight & BMI is also important for identifying those who may benefit from onward referral and for weight-adjusted medication dosing.

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.

There are two tiers of support on offer to improve the uptake of health checks for eligible patients at your practice:

1. Eclipse Detect – Activation of this programme will activate the BMI 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.

2. Eclipse Complete – Activation of this programme will automatically engage with prioritised patients via the PEGASUS platform to inform, educate and invite patients to provide an updated weight and height via an online questionnaire. If desired, telephone patient engagement to non-responders can be activated to allow a team of motivational interviewers to contact your patients to complete the questionnaire. Practices can activate Eclipse’s online booking system to allow responders to automatically book in for a weight/height if they cannot do this at home.

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 to provide their weight/height or opt for an appointment via access to their secure questionnaire portal.

COHORTS:

The cohort will be those without a coded weight or height within the last 3 years. Eclipse will enable prioritisation of eligible patients in relation to their results, and signpost for onward referral to educational and support programmes available for the patient.  

Once the patients have completed their questionnaires, they will be further segmented within the system into cohorts based on the patient preferences and actions required e.g. “patient is unable to provide an updated weight”, “patient with high BMI and needs secondary assessment” etc.

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:

1. Eclipse Detect - Practices that would like to activate Eclipse Detect to risk stratify and identify patients requiring prioritised weight/height, will undertake patient engagement and patient recalls through their own practice team.

2. Eclipse Complete - Practices that would like to activate Eclipse Complete will have all patient engagement and recalls undertaken for them through a centralised patient support hub.

3. 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.

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.