We have developed a series of proactive care frameworks to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, releasing clinician capacity and helping manage workload in practices.
The frameworks focus on atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma, COPD, heart failure, and serious mental illness.
The key elements of the frameworks are:
- Comprehensive search tools to risk stratify patients – built for EMIS and SystmOne.
- Pathways that prioritise patients for follow up, support remote delivery of care, and identify what elements of long-term condition care can be delivered by staff such as Health Care Assistants and link workers.
- Scripts and protocols to guide Health Care Assistants and others in their consultations.
- Training for staff to deliver education, self-management support and brief interventions. Training includes health coaching and motivational interviewing.
- Digital and other resources that support remote management and self-management.
Download the UCLPartners Proactive Care Frameworks
- UCLPartners Proactive Care Framework for AF
- UCLPartners Proactive Care Framework for Asthma Management
- UCLPartners Proactive Care Framework for Cholesterol
- UCLPartners Proactive Care Framework for COPD Management
- UCLPartners Proactive Care Framework for Diabetes
- UCLPartners Proactive Care Framework for Heart Failure
- UCLPartners Proactive Care Framework for Hypertension
- UCLPartners Proactive Care Framework for SMI (UCLP-Primrose)