LTC REVIEWS
Follow-Up
TABLE OF CONTENTS
Introduction
Once invites have been sent and initial reviews completed, there are some useful searches that will help practices follow up these patients efficiently and decide what they need to do next.
For QOF and Best Practice navigate to Arden's Ltd > LTC Reviews | QOF and Best Practice
For QOF only navigate to Arden's Ltd > LTC Reviews | QOF only
4 For questionnaires
The searches in this folder will allow practices to follow up any patient who has been sent their 1st invite and an Online Questionnaire more than 2 weeks ago but has yet to complete it or had their initial review completed. The searches have been divided up by condition to easily manage these patients. Practices can then chase these patients to fill out the questionnaire and then decide next steps.
NOTE: This searches exclude any patient that is coded as living in a Care Home or are Housebound. |
5 For follow up review
Once a patient has come in for their Initial Review, clinicians will tick the 'Initial LTC assessment done' box in the bottom right of the 'Initial Review & Tests' tab on the Long Term Condition Review template. This will add the code of 'Chronic disease initial assessment' (170557005 or 6617.) to that patients record, remove them from the Initial Invite searches, and after 3 days they will appear in the searches in this folder.
This then allows practices to review these patients, see what the result of the blood tests were and if there is anything else that needs to be done to the patient to complete their reviews. In some cases, if all QOF has been achieved in the Initial Appointment, and the bloods are fine, then a clinical decision can be made and there maybe no need to call the patient back in. Essentially, these searches act as a Virtual Ward of patients for practices to review.
The 'For follow-up review | All' search will show all patients on this list regardless of condition, or the searches are then divided up by various conditions to help practices manage these patients more effectively. For example, the 'For follow-up review | Has DM' will show all patients with Diabetes (but also may have other conditions) who may need a follow up, whereas the 'For follow-up review | Has DM only' will show patients that only have Diabetes and no other condition.
Patients will be removed from these searches once the 'Annual LTC review completed' box is ticked on the 'Follow-Up' Review tab of the Long Term Condition Review template. This adds the 'Chronic disease management annual review completed' (888461000000107 or Xaagy) code. This indicates everything has been completed for that QOF year. Patients will then be reset from April the following year to be invited again.
Patients also drop off these searches after 3 months if their Annual LTC reviews has not been completed - this is to keep these searches tidy - but these patients fall into another search in the '7 Review after' sub folder mentioned below.
6 For interim review
The Ardens LTC Recall process is designed for annual reviews, but some practices may wish to recall certain patients back after a few months dependent on their condition. The searches in this folder can be run to identify who these patients are.
Patients in these searches will have had the code of 'Annual LTC review completed' added to their notes in the last 9 months:
- For the CKD searches these patients will have CKD with G5A1 to G5A3 but not had their eGFR recorded in either 3, 4 or 6 months. Therefore they can be contacted and called back in for an interim review.
- For the Diabetic patients they would also not have had an HbA1c recorded in the last 7 months. These are then split into High, Intermediate and Low risk. Again, practices can contact these patients for a 6 month Diabetic review.
- For Heart Failure patients, these patients have not had a Heart Failure review for 6 months.
Of course some practices may decide to manage and recall their patients in another manner for these interim reviews. If so, the searches in this folder can be ignored.
7 Review after
The searches in this folder can be used to make sure no patients get missed off having their LTC Reviews completed on the template. Any patient that either had their initial review 2-3 months ago, or any patients where it has been more than 3 months since their initial review, but have not been coded as having their 'Annual LTC review completed' will appear in these searches. Practices can run these regularly to ensure all patients are being followed up correctly. In some cases, they may have had their reviews completed but the 'Annual LTC review completed' tick box on the Long Term Condition template may have been missed.
The 'Follow-up | ?For medication review as has current repeat and none in L12M and LTC review done in L3M' search will show patients who have had their LTC Review completed, but have repeat medication and have not had a medication review in the last year. If medication reviews are also done during the LTC Reviews, then practices can run this to make sure no patients get missed off having a medication review.
