Disclaimer
This process was developed for Penrose Health, and is based on NICE guidelines from April 2023.
You must have the appropriate training, use your clinical judgement, and escalate when necessary.
Why we do this
This review monitors the general health of patients with learning disabilities. It also allows us to create a personalised care plan for the patient, which aims to help them self-manage their condition.
Summary
A learning disability affects the way that a person learns new things. This may occur by impacting ability to direct attention, coordinate movements, do mathematical calculations or understand/use spoken or written language. However, the precise way that the condition presents itself differs from person-to-person.
Care pathways
Part of QOF and Premium Spec requirements
This pathway is designed to provide annual health checks for patients with a learning disability, and to allow us to work with the patient to generate a personalised care plan.
1️⃣ Book the appointment
Reception
- We are using a combination of platforms / tools / teams to book patients in correctly with minimal manual effort. If @Louis Williams hasn’t already been in touch, check out the page to find our Monthly Summary plans or reach out to him to find out what you should be doing:
- If we’re using Hippo Labs, log into app.hippolabs.co.uk to find patient lists (see for more information)
- If we’re using Hero Health or AccuRX, @Louis Williams will send your team manual excel recall lists
- Call the patient, or their carer, to book an appointment with a care coordinator
- After ending the call, send the patient the ‘Learning Disabilities Review (easy read)’ AccuRx text
Always check if the patient requires an interpreter (book double appointment if they do), if there’s anything else pending in the pink QOF box that we can address while we’re speaking with the patient, and that their contact details are correct
2️⃣ Care coordinator review
Care Coordinator (F2F)
- Open the clinical template: ‘Penrose Health - Learning Disabilities’ on EMIS
- Capture data on height, weight, smoking and alcohol status, and blood pressure and enter into the ‘Physical Check’ page of the template
- Create a Personalised Care & Support Plan (PCSP) with the patient
- Make additional appropriate referrals as below
- For BMI, refer to The Lambeth Healthy Weight Hub, Up! Up! Lewisham (Tier 2 Weight Management), NHS Tier 2 Weight Management Service or NHS Tier 3 Healthy Weight Programme as appropriate
- For smoking cessation, refer to Southwark Stop Smoking Service, Lewisham Stop Smoking Service or Lambeth Stop Smoking Service
- If the patient is 14 years old or over, has not had a blood test since April of this year and is happy to have one, book an appointment with an HCA to take bloods
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If a patient declines to have a blood test, do NOT push them to have one. If you think the patient would benefit from understanding more about blood tests, patient leaflets/videos can be found by clicking here.
3️⃣ Blood tests
HCA or Care Coordinator (F2F)
- Open the clinical template: ‘Penrose Health - Learning Disabilities’ on EMIS
- Draw bloods (HbA1c, FBC, eGFR, liver function, cholesterol, TSH)
- Offer flu vaccine if seasonally appropriate
4️⃣ Check & triage results
Lab Reports Team
- Review pathology results, and action as per the Lab Reports (Path Links) page. If, according to this page, a follow-up appointment is required, progress to step 5 below.
5️⃣ Follow-up appointment
Pharmacist or GP (F2F or remote)
- Open the clinical template: ‘Penrose Health - Learning Disabilities’ on EMIS
- Complete the ‘Assessment’ page of the template
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Resources for patient info/referral
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Prevalence
Resources: