Disclaimer
This process was developed for Penrose Health, and is based on [NICE/RCGP/etc.] guidelines from [Date of Publication]
You must have the appropriate training, use your clinical judgement, and escalate when necessary.
Why we do this
Summary
[what is this LTC for dummies]
Read about the relevant QOF indicators from NHSE here or summarised via NICE here
Care pathways
Part of QOF [and any other targets schemes relevant]
This pathway is designed to…
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 to book… [who to book with, if double appointment etc.]
Explain what the appointment is for, advise them that they’ll have a blood test on the day, and they they must produce a fresh urine sample on the day of their appointment [delete as applicable]
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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 Patient arrives for appointment
Reception
- Record that the patient has arrived in the appointment book
- Allow the patient a moment to relax before asking to capture data on height, weight, blood pressure, smoking status, and alcohol status (if possible) and add to patient’s EMIS record
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3️⃣ Carry out review
[team] (F2F or remote)
Always ensure you’re properly prepared, and the patient is comfortable and relaxed before starting the review.
- Use the clinical template: ‘name of template’ to complete the review
Tell the patient that they’ll be contacted with their test results. Alternatively, patients can check results themselves via Patient Access & the NHS App
4️⃣ Check & triage results
Clinical Admin
Traffic light system for LTC review results
- Green (low risk): if all test results fall into this category…
- Amber (moderate risk): if one or more test results fall into this category (and no results are high risk)…
- Red (high risk): if one or more test results fall into this category, task reception to book an appointment with a GP
Test | Low risk | Moderate risk | High risk |
5️⃣ Follow-up appointment for low / moderate risk patients
[team] (F2F or remote)
5️⃣ Follow-up appointment for high risk patients
[team] (F2F or remote)
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Resources for patient info/referral
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Prevalence
References: