Transcript Benefits for patients - Frome Valley Medical Centre

Clipstone Health Centre
Long term
condition
strategy
The Proposal (Mission Statement)
Clipstone Health Centre:
• Will operate a long term condition strategy that provides joined up,
patient centred care in dedicated appointments that address all the
patients’ issues and long term conditions.
• Will include housebound and residential care patients
• Will identify and manage high-risk patients and will work in
partnership with other agencies. It will fit seamlessly into the CCG
proposed provision of a virtual ward for the very high risk patients
• Will aim to provide the best care to our patients, using evidence
based guidelines, whilst streamlining workloads.
• Will be dependent on the development of the role of the HCA and
the practice nurses, and will result in nurse led long term condition
management
The current problem
The following case study is fictitious. There is
no resemblance intended to any living patient.
No slur is intended on any of the care or the
care givers at Clipstone Health Centre in the
following presentation. It is a gross
exaggeration of the current situation and
(hopefully) will make you smile!!
Meet Mr
Gawdelpme
In July Mr Gawdelpme
was sent a letter
asking him to come for
a CHD check – he
didn’t really
understand the letter,
so he ignored it. He
also ignored the next
letter
In July Mr Gawdelpme
was sent a letter
asking him to come for
a CHD check – he
didn’t really
understand the letter,
so he ignored it. He
also ignored the next
letter
In November the prescription
clerk noticed he was on
hypertension medication and
hadn’t had his UEs or BP
checked, so a message was put
on his prescription, asking him
to make an appt.
In November the prescription
In July Mr Gawdelpme clerk noticed he was on
was sent a letter
hypertension medication and
asking him to come for hadn’t had his UEs or BP
a CHD check – he
checked, so a message was put
didn’t really
on his prescription, asking him
understand the letter, to make an appt.
so he ignored it. He
also ignored the next
letter
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
In November the prescription
In July Mr Gawdelpme clerk noticed he was on
was sent a letter
hypertension medication and
asking him to come for hadn’t had his UEs or BP
a CHD check – he
checked, so a message was put
didn’t really
on his prescription, asking him
understand the letter, to make an appt.
so he ignored it. He
also ignored the next
He had a
letter
blood
pressure
check with
the HCA.
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
In November the prescription
In July Mr Gawdelpme clerk noticed he was on
was sent a letter
hypertension medication and
asking him to come for hadn’t had his UEs or BP
a CHD check – he
checked, so a message was put
didn’t really
on his prescription, asking him
understand the letter, to make an appt.
so he ignored it. He
also ignored the next
He had a
letter
blood
pressure
check with
the HCA.
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
When he requested his
prescription next, the
prescription clerk
noticed he still had not
had his UEs done, so
sent him another
message.
In November the prescription
In July Mr Gawdelpme clerk noticed he was on
was sent a letter
hypertension medication and
asking him to come for hadn’t had his UEs or BP
a CHD check – he
checked, so a message was put
didn’t really
on his prescription, asking him
understand the letter, to make an appt.
so he ignored it. He
also ignored the next
He had a
letter
blood
pressure
check with
the HCA.
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
When he requested his
prescription next, the
prescription clerk
noticed he still had not
had his UEs done, so
sent him another
message.
He booked
in and had
his UEs
done.
In November the prescription
In July Mr Gawdelpme clerk noticed he was on
was sent a letter
hypertension medication and
asking him to come for hadn’t had his UEs or BP
a CHD check – he
checked, so a message was put
didn’t really
on his prescription, asking him
understand the letter, to make an appt.
so he ignored it. He
also ignored the next
He had a
letter
blood
pressure
check with
the HCA.
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
When he requested his
prescription next, the
prescription clerk
noticed he still had not
had his UEs done, so
sent him another
message.
A month later he saw a
GP because his knees
were troubling him – GP
prescribed some pain
killers – did not address
any outstanding QOF
He booked
in and had
his UEs
done.
In November the prescription
In July Mr Gawdelpme clerk noticed he was on
was sent a letter
hypertension medication and
asking him to come for hadn’t had his UEs or BP
a CHD check – he
checked, so a message was put
didn’t really
on his prescription, asking him
understand the letter, to make an appt.
so he ignored it. He
also ignored the next
He had a
letter
blood
pressure
check with
the HCA.
His CKD annual review should have
been done when he came for his CHD
review, but he hadn’t come for that, so
he was sent a letter asking him to
collect a urine sample kit to send for
ACR.
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
When he requested his
prescription next, the
prescription clerk
noticed he still had not
had his UEs done, so
sent him another
message.
A month later he saw a
GP because his knees
were troubling him – GP
prescribed some pain
killers – did not address
any outstanding QOF
He booked
in and had
his UEs
done.
In November the prescription
In July Mr Gawdelpme clerk noticed he was on
was sent a letter
hypertension medication and
asking him to come for hadn’t had his UEs or BP
a CHD check – he
checked, so a message was put
didn’t really
on his prescription, asking him
understand the letter,
to make an appt.
so he ignored it. He
also ignored the next
He had a
letter
blood
He
didn’t
collect
it
His CKD annual review should have
been done when he came for his CHD
review, but he hadn’t come for that, so
he was sent a letter asking him to
collect a urine sample kit to send for
ACR.
pressure
check with
the HCA.
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
When he requested his
prescription next, the
prescription clerk
noticed he still had not
had his UEs done, so
sent him another
message.
A month later he saw a
GP because his knees
were troubling him – GP
prescribed some pain
killers – did not address
any outstanding QOF
He booked
in and had
his UEs
done.
It was now Nov
and he hadn’t
had his
depression
screening done
yet for his CHD –
he was sent a
letter with a
questionnaire for
him to complete
and return
In November the prescription
clerk noticed he was on
hypertension medication and
hadn’t had his UEs or BP
checked, so a message was put
on his prescription, asking him
to make an appt.
He
didn’t
collect
it
His CKD annual review should have
been done when he came for his CHD
review, but he hadn’t come for that, so
he was sent a letter asking him to
collect a urine sample kit to send for
ACR.
He had a
blood
pressure
check with
the HCA.
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
When he requested his
prescription next, the
prescription clerk
noticed he still had not
had his UEs done, so
sent him another
message.
A month later he saw a
GP because his knees
were troubling him – GP
prescribed some pain
killers – did not address
any outstanding QOF
He booked
in and had
his UEs
done.
When he came to make
the appt he forgot to
bring the message with
him and only
remembered that he
needed a blood
pressure, so that is what
he booked.
He returned it but
he didn’t answer all
the questions
It was now Nov
and he hadn’t
had his
depression
screening done
yet for his CHD –
he was sent a
letter with a
questionnaire for
him to complete
and return
He
didn’t
collect
it
His CKD annual review should have
been done when he came for his CHD
review, but he hadn’t come for that, so
he was sent a letter asking him to
collect a urine sample kit to send for
ACR.
He had a
blood
pressure
check with
the HCA.
When he requested his
prescription next, the
prescription clerk
noticed he still had not
had his UEs done, so
sent him another
message.
A month later he saw a
GP because his knees
were troubling him – GP
prescribed some pain
killers – did not address
any outstanding QOF
He booked
in and had
his UEs
done.
He returned it but Last year it took three letters
he didn’t answer all each a month apart before he
came in for his asthma review, so
the questions
now his recall date was 3 months
later than his CHD recall date –
It was now Nov
he was sent a letter to come in
and he hadn’t
for asthma review
had his
depression
He had a
screening done
blood
yet for his CHD –
pressure
he was sent a
check with
letter with a
He
the HCA.
questionnaire for
didn’t
him to complete
collect
and return
it
His CKD annual review should have
been done when he came for his CHD
review, but he hadn’t come for that, so
he was sent a letter asking him to
collect a urine sample kit to send for
ACR.
When he requested his
prescription next, the
prescription clerk
noticed he still had not
had his UEs done, so
sent him another
message.
A month later he saw a
GP because his knees
were troubling him – GP
prescribed some pain
killers – did not address
any outstanding QOF
He booked
in and had
his UEs
done.
He returned it but Last year it took three letters
he didn’t answer all each a month apart before he
came in for his asthma review, so
the questions
now his recall date was 3 months
later than his CHD recall date –
It was now Nov
he was sent a letter to come in
and he hadn’t
for asthma review
had his
depression
screening done
yet for his CHD –
he was sent a
letter with a
He
questionnaire for
didn’t
him to complete
collect
and return
it
His CKD annual review should have
been done when he came for his CHD
review, but he hadn’t come for that, so
he was sent a letter asking him to
collect a urine sample kit to send for
ACR.
He did attend for
his asthma review
but he was on
carbocisteine and
is an ex smoker –
he needed
spirometry. He
wasn’t asked for
the missing urine
sample or asked
about depression
A month later he saw a
GP because his knees
were troubling him – GP
prescribed some pain
killers – did not address
any outstanding QOF
He booked
in and had
his UEs
done.
He returned it but Last year it took three letters
He did attend for
he didn’t answer all each a month apart before he
his asthma review
came in for his asthma review, so
the questions
but he was on
now his recall date was 3 months
carbocisteine and
later than his CHD recall date –
is an ex smoker –
It was now Nov
he was sent a letter to come in
he needed
and he hadn’t
for asthma review
spirometry. He
had his
wasn’t asked for
depression
the missing urine
screening done
sample or asked
yet for his CHD –
about depression
he was sent a
letter with a
He
He was actually
questionnaire for
didn’t
feeling very low at the
him to complete
collect
time and DNA’d his
and return
it
spirometry appt
His CKD annual review should have
been done when he came for his CHD
review, but he hadn’t come for that, so
he was sent a letter asking him to
collect a urine sample kit to send for
ACR.
A month later he saw a
GP because his knees
were troubling him – GP
prescribed some pain
killers – did not address
any outstanding QOF
He booked
in and had
his UEs
done.
Mr Gawdelpme is 72 and has
CKD, CHD, Hypertension and
asthma (or was it COPD?!)
By the time he missed his
spirometry in March he was missing
10 QOF points and had missed
opportunities to have his
medications discussed, his chest
sorting out and his depression
addressed. He had had 5 letters, 2
messages on prescription and 4
appointments
The Long Term Condition
Management Strategy
Benefits for patients:
• Person centred care, incorporating mental and physical
processes
• Promotion of independence, maximum function, comfort
and quality of life
• Increased opportunities for involving patients in their
care, and for education
• Support for carers and families
• Reduction in medication problems
• Reduction in visits to surgery
The Long Term Condition
Management Strategy
Benefits for the practice:
• Potential reduction in emergency admissions
• Potential reduction in referrals
• Potential reduction of patients on SDL
• Polypharmacy managed effectively
• Reduction in overlapping workload
• QOF
• Happy patients!!
The changes
• Hypertension, AF, HF and PAD included in the annual
review recall
• First appt with HCA for a 20min health check. This health
check will be standardised across all the LTCs. Purpose
made template
• HCA tells the patient how long an appt to make with GP
or PN according to the patients’ conditions (perhaps
used ready made slips of paper to take to reception)
Exceptions
• Patients will be excepted if they make it clear on the
third, phone contact that they don’t wish to attend.
• Exceptions for ‘informed dissent’ will be applied to
patients notes in January, February and March each
year, giving the patient every opportunity to attend or be
advised to attend if comes for something else
Looking a bit further ahead
• Complex, high risk patients will be identified by appropriate methods
including new software and will be case managed with a named
contact (if not already under LM or AdlM)
• Expansion of the role of specialist services (eg diabetes
specialists/COPD specialists) and on-site education about specific
diseases
• These patients will be reviewed very regularly
• Closer collaboration with these 2 when necessary
• In time, could a GP be available to call on if necessary? (Perhaps if
long term condition reviews were only done on certain days of the
week?)
• A register of patients who don’t attend/who are excepted will be
compiled, and in time, other methods to get through to them devised