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Implementation of an integrated clinical care service to identify and optimise the management of patients at high risk of developing cardiovascular-renal and metabolic diseases across South East London

A Joint Working Project between Boehringer Ingelheim Ltd (BIL) and Guy’s & St Thomas’ NHS Foundation Trust (GSTTFT) to implement and evaluate a new model of care to identify and optimise the management of patients at high risk of developing cardiovascular-renal and metabolic (CRM) diseases. 

The NHS Long Term Plan supports primary care delivery to enable people to achieve recommended diabetes targets and drive down variation across CCGs and practices to minimise risk of future Complications1 . In England, the burden of CRM conditions has been shown to be substantial in terms of all-cause hospitalisation admission and costs, and this is amplified in the Type 2 Diabetes (T2D) population, particularly those with Heart Failure (HF). 

This joint working project will pilot an integrated clinical care service where community diabetes-renal and heart failure teams work together on the ‘one patient, one team in one community’ approach.   

Four key objectives will be addressed to ensure a sustainable model of care through; 

  • Establishing a new CRM pathway using existing clinical services/systems 

  • Early identification of patients at risk of CRM diseases 

  • Timely optimisation of care in line with national and international evidence-based guidelines 

  • Development and implementation of a CRM medical education programme 

The project aims to operationalise in April 2022 and is anticipated to run until January 2025. 

Boehringer Ingelheim Ltd is pleased to collaborate with Guy’s & St Thomas’ NHS Foundation Trust and explore the challenges and support needed to design and deliver an innovative, high-quality model of care for patients at high-risk of developing CRM diseases. 

 

References

1. NHS. The NHS Long Term Plan. Available at https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf (Last accessed Aug 2024)

 

NP-GB-104926      August 2024