Whole Systems Integrated Care (WSIC) Dashboards: Heart Failure

Transcription

1 Whole Systems Integrated Care (WSIC) Dashboards: Heart Failure User Guide v0.3 If you are having problems logging in, or require a new password, please contact the NWL Service Desk via If you are having nwlccg.servicedesk@nhs.net problems logging in, or require a new password, please contact the NWL Service Desk via nwlccg.servicedesk@nhs.net Please attach your user Please access attach form your in all user contact access with form the in Service all contact Desk.Website: with the Service Desk. Website: For feedback on the WSIC Dashboards please nwlccgs.wsic.dashboards@nhs.net For feedback on the WSIC Dashboards please nwlccgs.wsic.dashboards@nhs.net

2 Version History Date Version Author Notes 27/09/ Shilpi Begum and Tracey Dede First draft 11/11/ Dr Sadia Khan Amendments added 05/12/ Dr Brigitte Unger-Graeber Amendments added 06/02/ Shilpi Begum Updates and published Page 2

3 Contents Version History... 2 Section 1: Introduction to Heart Failure Dashboard... 8 Introduction... 9 Section 2: Step by Step Guide Heart Failure Dashboard Homepage Heart Failure Dashboard How to use the Dashboard Heart Failure Dashboard Landing Page Section 3: Calculation Definitions Heart Failure Landing Page (Population) Total Number of Patients Heart Failure Landing Page (Population) Number of Heart Failure Patients Heart Failure Landing Page (Population) HF Prevalence Heart Failure Landing Page (Population) Number of HFrEF Patients Heart Failure Landing Page (Clinical) Number of HF Patients with an Echo Referral Heart Failure Landing Page (Clinical) Number of HF Patients on Medication in the last 3M Page 3

4 Heart Failure Landing Page (Clinical) Number of HF Patients on ACE, ARBs, or ARNI in the last 3M Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed ACE in the last 3M Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed ARBs in the last 3M Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed ARNI in the last 3M Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed BB in the last 3M Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed MRA in the last 3M Heart Failure Landing Page (Clinical) Number of HF Patients who have End of Life Care Plan Heart Failure Landing Page (Finance) Number of HF Patients with two or more Unplanned Admissions within the last 6M Heart Failure Landing Page (Finance) Number of HF Patients with Secondary Care Activity Heart Failure Landing Page (Finance) Number of HF Patients seen within 2 Weeks of NEL Acute Discharge Heart Failure Landing Page (Finance) Average Spend Per Patient Heart Failure Landing Page (Life Style) Number of HF Patients offered Cardiac Rehabilitation Heart Failure Landing Page (Life Style) Number of HF Patients who Smoke Page 4

5 Heart Failure Landing Page (Life Style) Number of HF Patients who Drink Heart Failure Patient Radar Has Care Plan in last 12M Heart Failure Patient Radar Offered Cardiac Rehab in last 12M Heart Failure Patient Radar Heart Failure Exceptional Reporting in last 12M Heart Failure Patient Radar ECG in last 12M Heart Failure Patient Radar Blood Pressure Reading in last 12M Heart Failure Patient Radar Echo 3M before HF Diagnosis Heart Failure Patient Radar Is Smoker in last 12M Heart Failure Patient Radar ACE Inhibitor in last 3M Heart Failure Patient Radar Heart Rate in last 12M Heart Failure Patient Radar NYHA Classification Heart Failure Patient Radar HFpEF/HFrEF Heart Failure Medication Patients with at least one Echo since 3M before HF Heart Failure Medication Patients with ECG in last 12M Heart Failure Medication Patients with Clinical Review in last 6M Page 5

6 Heart Failure Medication Patients with more than two NEL in the last 6M Heart Failure Medication Patients concurrently on ACE/ARB/ARNI Heart Failure Medication Do they have Hypertension? Heart Failure Medication Do they have CHD? Heart Failure Medication Do they have Atrial Fibrillation (AF)? Heart Failure Medication Do they have Diabetes? Heart Failure Medication Do they have COPD? Heart Failure Medication Do they have CKD? Heart Failure Finance Number of Secondary Care Attendances Heart Failure Finance Number of Patients with Secondary Care Activity Heart Failure Finance Heart Failure Total Costs Heart Failure Finance Heart Failure Unplanned Costs Heart Failure Finance Heart Failure Planned Costs Section 4: Use Cases Heart Failure Dashboard Case Finding Page 6

7 Heart Failure Dashboard Treatment and Prescribing Section 5: Heart Failure Clinical Patient Radar Heart Failure Radar Introduction Clinical uses of the Heart Failure Radar Heart Failure Radar How to use the radar Page 7

8 Section 1: Introduction to Heart Failure Dashboard Page 8

9 Introduction Heart failure is a chronic condition that in many cases is the final common pathway for a number of cardiac conditions. As our population ages, and we become better at treating acute conditions such as myocardial infarction, the number of people living with heart failure will increase. We already spend around 1 %, ( 1 billion per year), of the total NHS budget looking after people with heart failure, with the majority of this money spent treating acute exacerbations in hospitals. Despite this: 1. Observed prevalence of heart failure in many of our communities is lower than expected 2. Mortality from heart failure is high, with around half of people living less than 5 years from diagnosis We know that optimising care processes has the potential to improve outcomes for patients, communities and the health system. We hope that this WSIC dashboard will help in highlighting those patients where proactive treatment can improve morbidity and facilitate care planning discussions. People who have left ventricular systolic function (LVSD ), whether symptomatic with their heart failure or not, will often benefit the most from optimisation of care, medications and processes as a simple rule of thumb treating LVSD with current best practice treatment can triple life expectancy. This is why you will see a focus on this in the dashboard. Page 9

10 Clinical Uses of Heart Failure Dashboard There are a number of scenarios where we envisage that the Heart Failure Dashboard may be of use: 1. Case finding of Heart Failure patients: Practices should check whether the prevalence of recorded Heart Failure is lower than expected - based on the characteristics of their population Identify high risk patients by a number of parameters including red flags, risk factors, age etc. who have out of date care processes 2. Prioritising patients for review: The Dashboard allows the clinician to sort patients by a number of parameters including NYHA Classification, HFrEF/HFpEF, Latest Care Provider and prescribed medication. 3. Virtual clinics / treatment optimisation Exception reporting Poorly controlled / off target patients o The dashboard allows the clinicians to review a list of Heart Failure patients with the following LTC such as Hypertension, CHD, Diabetes, COPD and AF. o The dashboard allows clinicians to see which patients with LVSD are receiving guideline based therapy 4. Recall for appointments o The medication overview section allows a health professional to see who has had or not had certain prescribed medication in any previous given period. Page 10

11 Section 2: Step by Step Guide Page 11

12 Heart Failure Dashboard Homepage You can access the Heart Failure Dashboard from the Homepage. Please refer to the How to Use section of this user guide, which explains some of the functionality of the Dashboard. From the landing page choose Population Health and select Heart Failure. Page 12

13 Heart Failure Dashboard How to use the Dashboard When accessing Heart Failure from the Population Health tab of the Homepage, six icons will appear to help navigate through the dashboard. Page 13

14 Heart Failure Dashboard Landing Page The landing page shows a top level view of the key care indicators from each of the four quadrants, this includes an analysis of the population, highlighting Heart Failure patients with Hypertension, AF, Diabetes and COPD. It allows viewing of aggregated data which details down to patient level. You can use the arrows at the bottom of each quadrant to explore into the selected area. Page 14

15 Heart Failure Dashboard Population Overview View total number of HF patients (Excluding any opt-out patients) Select HF prevalence by your CCG or Practice Compare HF prevalence by gender Page 15

16 Heart Failure Dashboard Medication Overview Select the organisation you re interested in viewing This allows the list to be filtered by the most recent provider the patient was seen by Notes on usage Clicking on the bars will generate a cohort of patients with the selected parameters. The list of patients can be viewed via the arrow below Total number of patients, this will change when applying filters. Click to view list of patients Page 16

17 Heart Failure Dashboard Medication Overview Patient List Click on arrow to return back to the Medication Dashboard Notes on usage List has been generated from the parameters selected on the Medication Dashboard Page 17

18 Heart Failure Dashboard Finance Indicators Breakdown of patient spend, this can be filtered to specific CCG and Practice using the dropdowns provided above. The total cost of HF and/or average spend per patient can be compared by CCG or Practice Comparison of cost for Planned and Unplanned admissions Page 18

19 Section 3: Calculation Definitions Page 19

20 Heart Failure Landing Page (Population) Total Number of Patients Total number of registered patients/population on WSIC. Heart Failure Landing Page (Population) Number of Heart Failure Patients This is the total number of Heart Failure Patients based on QOF Algorithm (HF001) Heart Failure Landing Page (Population) HF Prevalence Heart Failure Prevalence is calculated by dividing the number of Heart Failure Patients by the Total number of Patients. Heart Failure Landing Page (Population) Number of HFrEF Patients Number of HFrEF patients is determined using the GP Read Code, the following codes were used: G581., G5581, 33BA., 585f., G343., G5544, G555., G55y., G5yy9 Page 20

21 Heart Failure Landing Page (Clinical) Number of HF Patients with an Echo Referral Number of patients with an Echo Referral is determined using the following GP Read Codes: 5853., 58531, 585f., 585g., 5C20., 33BD., R1320, R1322, 5531., 5533., 5538., 79380, 79382, 7P0H6, 8A544, 79352, 7P0H., 7P0H0, 7P0H1, 7P0H4 Heart Failure Landing Page (Clinical) Number of HF Patients on Medication in the last 3M Please follow excel link below Prescription ReadCode.xlsx Page 21

22 Heart Failure Landing Page (Clinical) Number of HF Patients on ACE, ARBs, or ARNI in the last 3M Please follow excel link below ACE, ARBs, ARNI List.xlsx Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed ACE in the last 3M Please follow excel link below ACE List.xlsx Page 22

23 Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed ARBs in the last 3M Please follow excel link below ARBs List.xlsx Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed ARNI in the last 3M The following Prescription ReadCodes have been used for Heart Failure patients who have been prescribed ARNI in the last 3 months: bkl1., bkl2., bkl3., bkl4., bkl5., bkl6. Page 23

24 Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed BB in the last 3M Please follow excel link below Beta Blocker List.xlsx Heart Failure Landing Page (Clinical) Number of HF Patients Prescribed MRA in the last 3M The following Prescription ReadCodes have been used for Heart Failure patients who have been prescribed MRA in the last 3 months: b43.., b431., b432., b433., b43k., b43l., b51j., b43m., b43n., b43z., b45.., b45y., b45z. Page 24

25 Heart Failure Landing Page (Clinical) Number of HF Patients who have End of Life Care Plan The following ReadCodes have been used to determine Heart Failure patients who have had End of Life Care Plans: 8CMb., 8CMe., 8CME., 8CMg., 8CMG7, 8CMj., 8CMk., 8CN3., 8CN4., 8CN5., 8CPC., 93D.., 9NSY. Heart Failure Landing Page (Finance) Number of HF Patients with two or more Unplanned Admissions within the last 6M Patients with more than two emergency admissions (Admission Method 2) in the last 6 months are coded using ICD10 and HRG codes: ICD10 Codes: I110, I119, I255, I130, I131, I132, I1420, I429, I500, I501, I509, I110, I130 HRG Codes: EB03A, EB03B, EB03C, EB03D, EB03E, EB03H, EB03I Page 25

26 Heart Failure Landing Page (Finance) Number of HF Patients with Secondary Care Activity The number of Heart Failure patients with secondary care activity includes, Total Planned, Unplanned admissions and Outpatient Appointments in the last 24 months. The following codes were used: ICD10 Codes: I110, I119, I255, I130, I131, I132, I1420, I429, I500, I501, I509, I110, I130 HRG Codes: EB03A, EB03B, EB03C, EB03D, EB03E, EB03H, EB03I TFC Codes: 320, 430 Heart Failure Landing Page (Finance) Number of HF Patients seen within 2 Weeks of NEL Acute Discharge Number of Patients seen within 2 weeks of an Emergancy Admission (HF ICD10/HRG Codes) in Outpatient (HF TFC Codes), Non Emergancy Admission (HF ICD10,HRG Codes) or GP Appointment (any) Heart Failure Landing Page (Finance) Average Spend Per Patient The average spend per patient is worked out through dividing the cost by activity Page 26

27 Heart Failure Landing Page (Life Style) Number of HF Patients offered Cardiac Rehabilitation The following GP Read Codes were used to determine the Number of Heart Failure patients that were offered Cardiac Rehabilitation: 8F9.., 8Hkk., ZV579, 8H7v., 8F97., 8F92., 8I3a., 8Hkl., 8F98., 8F91., 9NSV., 8F99., 8F90., 8IE3. Heart Failure Landing Page (Life Style) Number of HF Patients who Smoke This is the number of patients who have been identified as current smokers. The following GP Read Codes have been used: 137.., 1372., 1373., 1374., 1375., 1376., 137a., 137b., 137c., 137d., 137e., 137f., 137G., 137h., 137H., 137J., 137m., 137o., 137P., 137Q., 137R., 137V., 137X., 137Y., 137Z. Page 27

28 Heart Failure Landing Page (Life Style) Number of HF Patients who Drink This is the number of patients who have been identified as a current drinker. The following GP Read Codes have been used: 136.., 1362., 1363., 1364., 1365., 1366., 136a., 136c., 136d., 136F., 136G., 136H., 136I., 136J., 136K., 136L., 136N., 136O., 136P., 136Q., 136R., 136S., 136T., 136V., 136W., 136Z., 2577., E23.., E231., E23z., E250., E2500, Eu10., Eu101, Eu102, ZV4KC Heart Failure Patient Radar Has Care Plan in last 12M The GP Read Codes used for this are: 8CMb., 8CMe., 8CME., 8CMg., 8CMG7, 8CMj., 8CMk., 8CN3., 8CN4., 8CN5., 8CPC., 93D.., 9NSY. Heart Failure Patient Radar Offered Cardiac Rehab in last 12M The GP Read Codes used for this are: 8F9.., 8Hkk., ZV579, 8H7v., 8F97., 8F92., 8I3a., 8Hkl., 8F98., 8F91., 9NSV., 8F99., 8F90., 8IE3. Page 28

29 Heart Failure Patient Radar Heart Failure Exceptional Reporting in last 12M The GP Read Codes used for this are: 9hH.., 9hH0., 9hH1. Heart Failure Patient Radar ECG in last 12M The data source for this recording comes from both the Hospital Data (HRG) and GP data (Read Code) using the latest event. GP Read Codes: ECG ReadCode List.xlsx HRG Codes: EA47Z, EC22Z, EY12A, EY12B, EY13Z, EY51Z Page 29

30 Heart Failure Patient Radar Blood Pressure Reading in last 12M Both Systolic and Diastolic need to be present in order to have an active flag. The following GP Read Codes were used to obtain this: 246a., 246A., 246c., 246f., 246L., 246P., 246R., 246T., 246V., 246X., 246m., 2469., 246b., 246d., 246e., 246K., 246N., 246Q., 246S., 246W., 246Y., 246l. Heart Failure Patient Radar Echo 3M before HF Diagnosis The data source for this comes from both Hospital data (HRG) and GP data (Read Code), using the latest event. The following codes were used: GP Read Codes: 5853., 58531, 585f., 585g., 5C20., 33BD., R1320, R1322, 5531., 5533., 5538., 79380, 79382, 7P0H6, 8A544, 79352, 7P0H., 7P0H0, 7P0H1, 7P0H4 HRG Codes: EA45Z, EC21Z, EY50Z, RA60A, RA60B, RA60C, RA60Z, RD51A, RD51B, RD51C Page 30

31 Heart Failure Patient Radar Is Smoker in last 12M These are patients who have been identified as current smokers. The GP Read Codes used for this are: 137.., 1372., 1373., 1374., 1375., 1376., 137a., 137b., 137c., 137d., 137e., 137f., 137G., 137h., 137H., 137J., 137m., 137o., 137P., 137Q., 137R., 137V., 137X., 137Y., 137Z. Heart Failure Patient Radar ACE Inhibitor in last 3M Please follow excel link below: ACE List.xlsx Heart Failure Patient Radar Heart Rate in last 12M The GP Read Code used for this field was: 24c.. Page 31

32 Heart Failure Patient Radar NYHA Classification The GP Read Codes used to determine the NYHA Classification are: 662i., 662h., 662g., 662f. Heart Failure Patient Radar HFpEF/HFrEF Patients latest code either HFpEF or HErEF, will be coded as unknown if both are coded on the same day. The GP Read Codes used are: G583., G5yyA, 585g., G581., G5581, 33BA., 585f., G5544, G555., G55y., G5yy9, G343. Heart Failure Medication Patients with at least one Echo since 3M before HF The data source for this field comes from both Hospital data (HRG) and GP data (GP Read Code), using the latest event. The codes used are: GP Read Codes: 5853., 58531, 585f., 585g., 5C20., 33BD., R1320, R1322, 5531., 5533., 5538., 79380, 79382, 7P0H6, 8A544, 79352, 7P0H., 7P0H0, 7P0H1, 7P0H4 HRG Codes: EA45Z, EC21Z, EY50Z, RA60A, RA60B, RA60C, RA60Z, RD51A, RD51B, RD51C Page 32

33 Heart Failure Medication Patients with ECG in last 12M The data source for this field comes from both Hospital data (HRG) and GP data (GP Read Code), using the latest event. The codes used are: GP Read Codes: ECG ReadCode List.xlsx HRG Codes: EA47Z, EC22Z, EY12A, EY12B, EY13Z, EY51Z Heart Failure Medication Patients with Clinical Review in last 6M The GP Read Codes used: 9Or0., 662W., 662p., 661N5 Page 33

34 Heart Failure Medication Patients with more than two NEL in the last 6M Patients with two or more Emergency Admissions (Admission Method 2) in the last six months are based on the following HRG and/or ICD10 Codes: ICD10 Codes: I110, I119, I255, I130, I131, I132, I1420, I429, I500, I501, I509, I110, I130 HRG Codes: EB03A, EB03B, EB03C, EB03D, EB03E, EB03H, EB03I Heart Failure Medication Patients concurrently on ACE/ARB/ARNI Please follow excel link: ACE, ARBs, ARNI List.xlsx Page 34

35 Heart Failure Medication Do they have Hypertension? The total number of Heart Failure patients who also have Hypertension based on QOF Algorithm. Heart Failure Medication Do they have CHD? The total number of Heart Failure patients who also have CHD based on QOF Algorithm. Heart Failure Medication Do they have Atrial Fibrillation (AF)? The total number of Heart Failure patients who also have AF based on QOF Algorithm. Heart Failure Medication Do they have Diabetes? The total number of Heart Failure patients who also have Diabetes based on QOF Algorithm. Heart Failure Medication Do they have COPD? The total number of Heart Failure patients who also have COPD based on QOF Algorithm. Page 35

36 Heart Failure Medication Do they have CKD? The total number of Heart Failure patients who also have CKD based on QOF Algorithm. Page 36

37 Heart Failure Finance Number of Secondary Care Attendances The number of secondary care attendances includes the total number of Planned and Unplanned admissions and Outpatient Appointments in the last 24 months. The following codes were used: ICD10 Codes: I110, I119, I255, I130, I131, I132, I1420, I429, I500, I501, I509, I110, I130 HRG Codes: EB03A, EB03B, EB03C, EB03D, EB03E, EB03H, EB03I TFC Codes: 320, 430 Heart Failure Finance Number of Patients with Secondary Care Activity This is the total count of patients who have secondary care activity. Page 37

38 Heart Failure Finance Heart Failure Total Costs The total cost of Heart Failure is calculated with SUS costs using PBR Tariff, Spells and Outpatient Activity. The following codes are used: ICD10 Codes: I110, I119, I255, I130, I131, I132, I1420, I429, I500, I501, I509, I110, I130 HRG Codes: EB03A, EB03B, EB03C, EB03D, EB03E, EB03H, EB03I TFC Codes: 320, 430 Heart Failure Finance Heart Failure Unplanned Costs The Unplanned Costs are calculated with SUS Costs using PBR Tariff, Spells and Outpatient Activity only for admission method 2 (Unplanned). The following codes were used: ICD10 Codes: I110, I119, I255, I130, I131, I132, I1420, I429, I500, I501, I509, I110, I130 HRG Codes: EB03A, EB03B, EB03C, EB03D, EB03E, EB03H, EB03I Page 38

39 Heart Failure Finance Heart Failure Planned Costs The Planned Costs are calculated with SUS Costs using PBR Tariff, Spells and Outpatient Activity only for admission method 1 (planned). The following codes were used: ICD10 Codes: I110, I119, I255, I130, I131, I132, I1420, I429, I500, I501, I509, I110, I130 HRG Codes: EB03A, EB03B, EB03C, EB03D, EB03E, EB03H, EB03I Page 39

40 Section 4: Use Cases Page 40

41 Heart Failure Dashboard Case Finding Heart Failure is a long term condition that gradually gets worse over time, although there is no cure, proactive management including treatment and lifestyle changes will ensure patients can have a good quality of life. In accordance to clinical best practice (NICE NG106), the primary care team should carry out the following for people with Heart Failure: Conduct a full review of the person s heart failure care, which may form part of the long-term conditions review Recall the patient at least every six months and update the clinical record Arrange access to specialist heart failure services if needed Take over routine management of heart failure once stabilized and in line with any shared care agreements A review of medication, including need for changes and possible side effects Page 41

42 Heart Failure Dashboard Treatment and Prescribing As with many other chronic diseases, Heart Failure can have an influence on lifestyle as well as be a risk factor/ link to many co-morbidities which will require individual management: Heart failure patients will commonly have AF, this will complicate the course and treatment of the other. The Heart Failure dashboard will help to ensure proactive management of this select cohort of patients and monitor their medication and care management. Hypertensive patients with Heart Failure can also be identified through the dashboard. Medication used to treat Hypertension can in turn help to treat Heart Failure, this includes the use of ACE inhibitors. Heart Failure patients with Coronary Heart Disease (CHD) will require extensive and long term management, the dashboard will ensure that the medications of these patients are reviewed alongside the patient s lifestyle factors. These patients will be encouraged to stop smoking or reduce alcohol consumptions and exercise more. Diabetes and Heart Failure are closely related, Diabetes is highly prevalent in patients with Heart Failure. Beta Blockers are commonly prescribed to Heart Failure patients (with or without Diabetes). However, diabetic heart failure patients will need to monitor their use of beta blockers carefully as they can mask hypoglycaemia if on insulin or gliclazides. Page 42

43 COPD and Heart Failure both cause shortness of breath for different reasons, therefore both will need to be treated to determine the cause of patient s symptoms. The dashboard will provide an overview of the medications that have been provided to the Heart Failure and COPD patient and ensure proactive intervention will take place if select medications are not working. The medication can be reviewed via the Medication Overview page on the Heart Failure Dashboard. Heart Failure is highly prevalent in patients with Chronic Kidney Disease (CKD), it is important to control the blood pressure within these patients. The dashboard will help to review the medications that have been prescribed to treat Heart Failure within CKD patients. Common medications include ACE inhibitors and beta blockers. Page 43

44 Section 5: Heart Failure Clinical Patient Radar Page 44

45 Heart Failure Radar Introduction The Heart Failure Radar is a patient list combined view of the nine Key Care processes for direct care use. This provides a case finding tool that s easy to view. Clinical uses of the Heart Failure Radar There are a number of scenarios where we envisage that the Heart Failure radar may be of use: 1. Prioritising patients for review: o The radar allows the clinician to sort patients by a number of parameters including Patient name, Age, NYHA Classification, Key Care Processes outstanding, Date of Heart Failure Diagnosis, HFrEF/HFpEF and Latest Provider. 2. Virtual clinics: o Sitting down with a specialist clinician (e.g.: within secondary care) and reviewing a list of Heart Failure patients can be a relatively time efficient way of getting input into a group of poorly controlled / off-target patients. The radar allows the clinicians to review a list of patients sorted by Number of outstanding Care processes (or other parameters) quite rapidly without necessarily having to open every patient s set of notes in the GP system. 3. Recall for appointments Page 45

46 o Checking the individual for the out of date care processes may result in the Health Care professionals decision for the patient to be called in for an appointment to assess further. Page 46

47 Heart Failure Radar How to use the radar The Heart Failure Clinical Patient Radar displays traffic lights indicating how recently key care processes were completed for each patient with Heart Failure. The list can be viewed by the most recent provider in which the patient had visited. Each key care process will have their own timeframe in which they should have been completed by, this is indicated in the heading (e.g. 12M or 3M) Traffic Light Key: Red: No Care Process Yellow: Care Process out of Timeframe Green: Care Process in expected Timeframe Page 47

48 For more information, please Page 48