LTC REVIEWS

Overview

Initial Setup 

Getting Started

Sending Invitations

Follow-Up


TABLE OF CONTENTS


Introduction


Invitations are sent using clinical reporting and are based on the patient having a diagnosis of one of the conditions included in the searches, month of birth (or chosen month) and no code of 'Chronic disease management annual review completed' (888461000000107 or Xaagy), 'Chronic disease initial assessment' (170557005 or 6617.) or 'Chronic disease - default from follow-up' (170559008 or 6619.) added in the current financial year. 


NOTE: This invite process does not take into consideration if a specific chronic disease review code has been added to a patients notes.

E.g. For Asthma reviews, if a patient has been coded as having an Asthma Review by adding the 'Asthma annual review' (394700004 or Xaleq) code and everything has been achieved for QOF that financial year, but the Ardens LTC template has not been used to code and complete all the reviews, they will still appear in the Ardens LTC invite searches.

The only codes that remove them from the invite searches will be the 'Chronic disease management annual review completed' (888461000000107 or Xaagy), 'Chronic disease initial assessment' (170557005 or 6617.) or 'Chronic disease - default from follow-up' (170559008 or 6619.) codes mentioned above. By using the Ardens LTC Recall system and template it is easy to add these codes so the process should work smoothly, but if this process is adopted in the middle of the financial year, it is worth remembering this point in case patients get invited in unnecessarily.


The invites work as follows:

  • 1st invite is set-up to be sent just before the month of their birthday.
  • 2nd invite at least 3 weeks after the first invite.
  • 3rd invite a further 3 weeks after that. 


Practices have a choice between inviting for just QOF conditions, or QOF and Best Practice Conditions. There are two separate folders for these, and individual practices can choose the folder they wish to use. The rest of the process is exactly the same, regardless of which choice.


1st Invites

For QOF and Best Practice navigate to Arden's Ltd > LTC Reviews | QOF and Best Practice > 3 For initial review | For 1st invite


For QOF only navigate to Arden's Ltd > LTC Reviews | QOF only > 3 For initial review | For 1st invite

The searches in this folder are then divided by month of birth. These always look at the next month, so for example in the screenshot above, these searches will show all the patients with the relevant conditions who have a birth month of October - and these invites can be sent in September to give time for them to book their appointments.


Each month is then divided into the following options for practices to use:


  • All

    This is all patients with the relevant conditions in that birth month, regardless of preferred contact method, age or any reasonable adjustments.

  • Consider method as <16y

    This is all patients with the relevant conditions who are under the age of 16. This allows practices to manage and decide how they want to invite these patients in for their LTC Reviews.


  • Consider method as EOL/Dementia/LD/Reasonable Adjustment (Use report output)

    Patients included in this report will have the relevant birth month but also would have been coded with any of the following diagnoses - End of Life, Dementia, Learning Disability or having a Reasonable Adjustment. Therefore by using this report practices can manage these patients individually and decide how they should be invited as appropriate to their personal requirements.

    To help with this, and to view which of these groups these patients fall into and what necessary reasonable adjustments need to be made, a report output has been created for practices to use.

    Run the report and then Right Click > Show Patients
    Use the 'Select Output' option above the patient list to select 'Pre-defined report output' and then select the report output called 'Consider Invite Method - LD/SMI/Dementia/EOL/RA'.


    This will then allow staff to work through the list individually and decide how best to contact and/or approach each patient about their LTC Reviews. There may be some patients you wish to contact in bulk from this list, and this can be actioned as normal.

NOTE: This report excludes all patients under 16.


  • Electronic/Communications Annexe (SMS/email/airmid/unkown

    Any patient that has a preferred contact method of SMS, email, airmid or unknown will appear in this search. This means practices can send invites in bulk to these patients by using the Communications Annexe and then choosing the 'use preferred contact method' option. Practices could also use AccurX or any other 3rd party system to bulk send these as well.

    To use the Communications Annexe in bulk, run the report and then choose 'Show Patients'. The relevant patients need to be highlighted, and then Right Click > Actions > Use Communications AnnexeThe following window will open, which will allow users to tick the 'Use preferred contact method' tick box highlighted. Then the relevant invite message can be written or selected from a list of local presets. When the message is ready, just press 'Send' and this will send it to all the patients that were highlighted in the report.
    This bulk action can also be done from the report name, without having to actually 'Show Patients'. Once the report has run, simply Right Click > Actions > Use Communications Annexe on the name of the report.

    (For more information on using the Communications Annexe and Presets please see this support article)

NOTE: This report excludes patients in both the Consider method as <16y and Consider method as EOL/Dementia/LD/Reasonable Adjustment (Use report output) reports.


  • Letter

    Any patient whose preferred contact method is Letter will appear in this search. This means practices can bulk send a letter to these patients to invite them.

    To do this, run the report and then choose 'Show Patients'. The relevant patients need to be highlighted, and then Right Click > Actions > Print Integrated Word LettersThe following window will appear where you can select the specific 'Letter Type' that the letter will be saved to the patient record as.
    Then another window will appear which has all the letters stored on SystmOne at that practice. Ardens have built some preset letters practices can use to send their invites. To find these, go to the following folder: Ardens > Invitations. You will then have a list of all the preset letters that you can choose from. For example, if this was the 1st Invite for QOF & Best Practice conditions, then you could select the 'LTC Review 1st Invitation - QOF + Best Practice' letter and then click 'Ok'.

    The letter will then open in word, which can be reviewed, and then when happy press the 'Merge & Print' button in the top left of word. This will merge and print the letters and save a copy in each patients notes.

    This bulk action can also be done from the report name, without having to actually 'Show Patients'. Once the report has run, simply Right Click > Actions > Print Integrated Word Letters on the name of the report.

    If practices wish to copy and amend the default Ardens invite letter, then please follow the instructions here


NOTE: This report excludes patients in both the Consider method as <16y and Consider method as EOL/Dementia/LD/Reasonable Adjustment (Use report output) reports.


  • No communication

    Patients in this report will have a preferred contact method of 'No Communication'. Practices can decide what they want to do with these patients with regards to inviting them in.

NOTE: This report excludes patients in both the Consider method as <16y and Consider method as EOL/Dementia/LD/Reasonable Adjustment (Use report output) reports.


Adding The Invite Code

Once any of the invite processes listed above are sent, it is important to code each patient with the correct invite code to take them off the 1st Invite searches and eventually move then onto the 2nd Invite searches. 


This can be easily done in bulk. From any of the searches listed above, once the relevant patients have been sent their invite, another bulk action needs to be performed against these patients. Simply Right Click > Actions > Add Read Code


The following window will then open:

By clicking on the Icon next to 'Read Code' the code browser will open and any read code or Snomed code can be searched for and selected.


Then the code of 'Long term condition care planning invitation' (912641000000104 or XabEd) must be selected:

Then choose the date of the code (if backdating it) and click OK to bulk add this to all patients in bulk:

Once this code has been added, when the 1st invite reports mentioned above are re-run the next working day, any patient that has had that code added to their record will no longer show up on the 1st Invite searches, as they have now already been invited.


NOTE: Preset codes can be added on the right of this window so they can be easily selected next time a bulk code is added. Simply click 'Add to presets' and the find the code you want and click OK.


NOTE: We have not included the QOF Invite code at the point of sending the invite in this process. This is because adding these codes twice automatically adds an exemption for the relevant QOF Indicator, and the QOF Alerts will disappear from the patients record.

Once TPP release the QOF reports for 2025/26 we will build some extra searches for practices to run at the end of the QOF year. These will find patients who still have QOF work to do so they can be easily managed and exempted if necessary.


2nd Invites

For QOF and Best Practice navigate to Arden's Ltd > LTC Reviews | QOF and Best Practice > 3 For initial review | For 2nd invite


For QOF only navigate to Arden's Ltd > LTC Reviews | QOF only > 3 For initial review | For 2nd invite

Once a patient has had their 1st invite, if they have not come in for either their Initial Appointment and been coded with 'Chronic disease initial assessment' (170557005 or 6617.) or had their Annual LTC Review Completed and coded with 'Chronic disease management annual review completed' (888461000000107 or Xaagy) from the Long Term Condition Review template, after 3 weeks they will fall into the 2nd Invites. Patients remain in these searches for 3 months or until they are sent a 2nd invite and coded as appropriate.


The format and method for the 2nd Invites is the same as listed above in the 1st Invites section, so practices can send a reminder in the same way as they sent their 1st invites.


Once the 2nd invite is sent, practices must bulk add the invite code of 'Long term condition care planning invitation' (912641000000104 or XabEd) as mentioned in the 'Adding The Invite Code' section above.


  • ?For 2nd invite - 1st invite >3M ago and no 2nd invite

    Any patient that has had their 1st invite more than 3 months ago, without having a 2nd invite in that time (or without having their Initial Assessment or Annual LTC Review Completed) will appear in this search. This allows practices to prioritise these patients and chase them up so they don't get missed.


3rd Invites

For QOF and Best Practice navigate to Arden's Ltd > LTC Reviews | QOF and Best Practice > 3 For initial review | For 3rd invite


For QOF only navigate to Arden's Ltd > LTC Reviews | QOF only > 3 For initial review | For 3rd invite

Once a patient has had their 2nd invite, if they have not come in for either their Initial Appointment and been coded with 'Chronic disease initial assessment' (170557005 or 6617.) or had their Annual LTC Review Completed and coded with 'Chronic disease management annual review completed' (888461000000107 or Xaagy) from the Long Term Condition Review template, after 3 weeks they will fall into the 3rd Invites. Patients remain in these searches for 3 months or until they are sent a 3rd invite and coded as appropriate.


The format and method for the 3rd Invites is the same as listed above in the 1st and 2nd Invites section, so practices can send a reminder in the same way as they sent their 1st and 2nd invites.


Once the 3rd invite is sent, practices must bulk add the invite code of 'Long term condition care planning invitation' (912641000000104 or XabEd) as mentioned in the 'Adding The Invite Code' section above.


  • ?For 3rd invite - 2nd invite >3M ago and no 3rd invite

    Any patient that has had their 2nd invite more than 3 months ago, without having a 3rd invite in that time (or without having their Initial Assessment or Annual LTC Review Completed) will appear in this search. This allows practices to prioritise these patients and chase them up so they don't get missed.

  • ?For review - 3rd invite >3M ago

    Patients that have been sent their 3rd invite more than 3 months ago, but have not come in for their Initial Appointment and been coded with 'Chronic disease initial assessment' (170557005 or 6617.) or had their Annual LTC Review Completed and coded with 'Chronic disease management annual review completed' (888461000000107 or Xaagy) will appear in this search. This acts like a 'safety net' so any patient that hasn't responded to invites can be picked up. Practices can then decide what to do with these patients - whether to invite them in a 4th time, or except them from their relevant QOF indicators.


Visits

For QOF and Best Practice navigate to Arden's Ltd > LTC Reviews | QOF and Best Practice > 3 For initial review | For Visit


For QOF only navigate to Arden's Ltd > LTC Reviews | QOF only > 3 For initial review | For Visit

These searches allow practices to identify any patients who are coded as being a Care Home Resident and/or Housebound. Practices can then use these lists to organise visits to make sure these patients have their annual reviews. These aren't broken down into month of birth or have invite codes as they would be dealt with separately depending on the practice.


  • Care Home Resident - All

    This search will include all patients coded as living in a Care Home, whether they have a code of Housebound or not.

  • Care Home Resident - Housebound

    This search will only include patients coded as living in a Care Home and having a code to say they are Housebound.

  • Care Home Resident - Not housebound

    This search will only include patients coded as living in a Care Home but are not coded as Housebound.

  • Housebound - Not care home resident

    This search will include any patient coded as Housebound but not coded as living in a Care Home.


Note: The patients in the Visits searches are not included in any of the other invite searches listed above.


Viewing Patients Conditions

When you run any of the searches listed in the process above and choose 'See Patients', you will just get a list of patients and their address. Some practices find it useful to know exactly what conditions each patient has in case they want to prioritise and invite for specific conditions rather than send and invite to all patients in bulk. To help with this, Ardens have created a Report Output to allow you to view each condition a patient has.


On the invitation reports you can select the relevant LTC Diagnosis report output to see a grid of the patients and their diagnosis. To do this:

  • Run the invitation report and then Right Click > Show Patients
  • At the top of this screen, click ‘Select Output’
  • Click ‘Pre-defined report output’. You then have a choice of 'LTC Diagnosis - QOF + Best Practice' or 'LTC Diagnosis - QOF only'. Choose the option depending on which conditions you are inviting in for, and click OK.

You will then see a grid of the patients with their different diagnosis.

  • Click the top of each column on the LTC name to sort the rows by this diagnosis.
  • You can then select the patients that you wish to send an invite to depending on their diagnosis and exclude those you do not want to send an invite to.

Next: Follow-Up