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 and COPD.
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.
The CVD LTC and stratification tools are wonderful…super-easy to upload and already in a few days making a difference to patient care and staff resilience in my PCN. Picked up some quick wins and new determination to get things right.Dr Hannah Morgan, GP and Clinical Director for Hayling Island and Emsworth PCN, South East Hampshire
The UCLPartners’ tools give us a clear mechanism of risk stratifying patients with long-term conditions, developing the wider workforce, such as pharmacists and HCAs, and have the ability to demonstrate clear improvement in outcomesDr Ken Aswani, Chair of Waltham Forest CCG