Community outreach to improve CVD outcomes in West Yorkshire
Patient case study
the life of the project , we played a central role in project scoping , planning , ensuring data analysis was being undertaken and reported on and that governance arrangements and oversight from the respiratory clinical network was robust . We helped maintain local relationships with primary care and provided support to the integrated care system when they were reporting to NHS England .
The positive outcomes for patients include :
• More than 430 health care professionals across Humber and North Yorkshire received severe asthma education to enable them to better support patients .
• A total of 253 severe asthma patients who were potentially eligible for asthma biologics were identified through electronic health record searches .
• 80 patients were then identified and invited for a clinical review .
• 17 patients completed a second review prior to referral for asthma biologics .
26 Transforming Lives Through Innovation
Community outreach to improve CVD outcomes in West Yorkshire
In South East Leeds , we supported a community-based CVD and lipid outreach project . We collaborated with community organisations including Leeds GATE , Hamara , and BITMO who were instrumental in facilitating engagement with the Gypsy , Traveller , and Roma communities . The aim of this project was to better meet their health and care needs with a particular focus on point of care testing and outreach care .
This outreach initiative helped the multidisciplinary CVD team within the West Yorkshire Integrated Care Board build strong , trusted relationships with these community groups , welcoming them into traveller sites and homes for further health discussions .
The positive outcomes for patients include :
• 203 people were seen in community settings .
• 180 people received a blood pressure check ; 137 people had point of care cholesterol check ; 9 people who had no previous cholesterol test were identified as having a cardiovascular risk greater than 20 per cent
• 6 patients started using statins ; 9 patients had lipid or blood pressure treatments optimised .
• 1 patient was newly diagnosed with hypertension .
• 42 patients were signposted to a GP and 9 signposted to community pharmacies .
Patient case study
At an outreach event , a male in his mid-60s , residing at a Leeds Council-run caravan site , interacted with the team . Previously , he had attended GP appointments sporadically , during our appointment he was diagnosed with high blood pressure and cholesterol . Due to limited English literacy , the gentleman didn ’ t understand his medications , leading him to stop taking several long-term , important medicines . Through this intervention , the multidisciplinary team were able to reinstate his medications and support him with a comprehensive plan .