UCLPartners has developed new search tools which will assist primary care teams across the country to identify which of their patients living with long-term conditions are most likely to have been put at risk during COVID-induced service disruptions.
The search tools, which underpin new guidance published by the Royal College of GPs (RCGP) today, will ensure those patients who need care most are given the support they need to avoid future health complications.
The pandemic has had a major impact on primary care as practice teams have risen to the challenge of covid surges and the vaccination programmes. Inevitably this has disrupted some routine, proactive care for patients with long term conditions such as cardiovascular disease, hypertension, diabetes, chronic obstructive pulmonary disorder (COPD), asthma. As we emerge from the pandemic, primary care has already started to tackle the challenge of recovering routine care for patients.
The new RCGP guidance highlights UCLPartners expertise to help primary care teams assess their patient population, identify who needs support most and then offer care that is tailored to their needs.
RCGP is recommending primary care teams offer earlier reviews to patients who have:
- Not been seen for over 12 months,
- A higher risk of deterioration and exacerbation due to an underlying condition such as diabetes, hypertension, respiratory disease or severe mental illness,
- Have potential undiagnosed asthma or COPD
Dr Matt Kearney, General Practitioner and Executive Clinical Director at UCLPartners said: “Primary care has weathered some of its toughest times during the COVID pandemic. It stepped up, adapted, and ensured care was provided in the best way possible to the patients with the most acute need. But now we must recover, refocus, and re-establish our efforts in helping our patients avoid future ill health.
“To achieve this, we first need to identify who is most at risk. This is why having the new UCLPartners search tools highlighted in national guidance is so important. These search tools will help practice teams to know which of their patients is in most urgent need of support, while continuing to provide high quality care to all their patients.”
How do the new searches align with the UCLPartners Proactive Care Frameworks?
The new searches provide details of patients who have not been seen for a Long-Term Conditions review in the last 12 months. They are therefore complementary but do not overlap with patients identified via the UCLPartners Proactive Care Frameworks
The UCLPartners Proactive Care Frameworks
In addition to these new searches, the UCLPartners Proactive Care Frameworks provide broader support to primary care practices to optimise care for patients with Long-Term Conditions.
The comprehensive framework resources include:
- Search and stratification tools that help practices to identify patients who need to be reviewed more urgently and those whose care can be safely phased over time
- Protocols for staff such as HCAs and wellbeing coaches to provide structured support for patient education, self-management and behaviour change
- Slide sets for clinicians – focusing on the ‘how-to’ of optimising clinical management in real world primary care
- Workforce training framework
- Implementation guidance
- Case studies
- Digital resources for staff and patients to support clinical care and self care.