1. Clipstone Health Centre Long term condition strategy

2. 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

3. 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!!

4. Meet Mr Gawdelpme

5. 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

6. 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 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

7. 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 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 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

8. He had a blood pressure check with the HCA. 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. 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.

9. When he requested his prescription next, the prescription clerk noticed he still had not had his UEs done, so sent him another message. 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 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 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 He had a blood pressure check with the HCA.

10. 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 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 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 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.

11. 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. 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 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 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. A month later he saw a GP because his knees were troubling him – GP prescribed some pain killers – did not address any outstanding QOF

12. 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. 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 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 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. A month later he saw a GP because his knees were troubling him – GP prescribed some pain killers – did not address any outstanding QOF 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.

13. 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. 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 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 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. A month later he saw a GP because his knees were troubling him – GP prescribed some pain killers – did not address any outstanding QOF 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 didn’t collect it

14. 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. 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. 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. A month later he saw a GP because his knees were troubling him – GP prescribed some pain killers – did not address any outstanding QOF 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 didn’t collect it 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

15. 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. He booked in and had his UEs done. A month later he saw a GP because his knees were troubling him – GP prescribed some pain killers – did not address any outstanding QOF 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 didn’t collect it 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 returned it but he didn’t answer all the questions

16. 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. He booked in and had his UEs done. A month later he saw a GP because his knees were troubling him – GP prescribed some pain killers – did not address any outstanding QOF 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 didn’t collect it 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 returned it but he didn’t answer all the questions Last year it took three letters each a month apart before he came in for his asthma review, so now his recall date was 3 months later than his CHD recall date – he was sent a letter to come in for asthma review

17. He booked in and had his UEs done. A month later he saw a GP because his knees were troubling him – GP prescribed some pain killers – did not address any outstanding QOF 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 didn’t collect it 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 returned it but he didn’t answer all the questions Last year it took three letters each a month apart before he came in for his asthma review, so now his recall date was 3 months later than his CHD recall date – he was sent a letter to come in for asthma review 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

18. He booked in and had his UEs done. A month later he saw a GP because his knees were troubling him – GP prescribed some pain killers – did not address any outstanding QOF 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 didn’t collect it 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 returned it but he didn’t answer all the questions Last year it took three letters each a month apart before he came in for his asthma review, so now his recall date was 3 months later than his CHD recall date – he was sent a letter to come in for asthma review 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 He was actually feeling very low at the time and DNA’d his spirometry appt

19. 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

20. 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

21. 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!!

22. 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)

23. 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

24. 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