LTC REVIEWS
Overview
TABLE OF CONTENTS
Introduction
Ardens offers a comprehensive approach to Long Term Conditions Reviews. Clinical reports & months of birth are used to send invitations to patients and a single template can then be used to perform the relevant reviews.
Conditions Included
Practices have a choice between inviting patients who just have a QOF condition, or a QOF and Best Practice Condition. The reports we have built for the process therefore pick up the following conditions:
QOF and Best Practice Conditions
| *Asthma | Gout + on ULT |
| Asthma COPD Overlap Syndrome | Heart Failure |
| Atrial Fibrillation | Hypertension |
| Bariatric Surgery | Hyperthyroidism |
| Bronchiectasis | Hypothyroidism |
| Chronic Heart Disease | Learning Disabilities |
| *Chronic Kidney Disease | MGUS |
| Coeliac Disease | NAFLD + NASH |
| COPD | *Non-diabetic Hyperglycaemia |
| CVD-PP - On statin or QRISK2/3 >10% | Peripheral Artery Disease |
| Dementia | Polycystic Ovary Syndrome |
| *Diabetes Mellitus | Primary Hyperparathyroidism |
| *Epilepsy | *Rheumatoid Arthritis |
| Familial Hypercholesterolaemia | Severe Mental Illness (including remission or on lithium therapy) |
| Frailty - Severe | Stroke or Transient Ischaemic Attack |
| Gestational Diabetes Mellitus |
QOF Only
| *Asthma (>=6y + asthma-related drugs prescribed in L12M) | Heart Failure |
| Atrial fibrillation | Hypertension |
| Chronic Heart Disease | Learning Disabilities |
| *Chronic Kidney Disease (>=18y + Stage 3-5) | *Non-diabetic Hyperglycaemia (>=18y) |
| COPD | Peripheral Artery Disease |
| Dementia | *Rheumatoid Arthritis (>=16y) |
| *Diabetes Mellitus (>=17y) | Severe Mental Illness (including remission or on lithium therapy) |
| *Epilepsy (>=18y + drug treatment in L6M) | Stroke or Transient Ischaemic Attack |
| *There are differences between some of the conditions covered in both the QOF & Best Practice and the QOF only searches. For example, if using QOF & Best Practice, any patient with a diagnosis of Asthma will be included, whether they have had asthma related drugs prescribed or not in the last year. Whereas in the QOF Only searches, this will be based purely off the QOF rules, so would only include Asthma patients over 6 and having had asthma related drugs prescribed in the last year. |
Basic Overview
Ardens use reports, not recalls, for sending invitations as reports are not reliant on users adding/superseding/removing recalls. They also do not require time to maintain if a new patient registers or a practice merges. Using this process also ensures only a single invitation is needed to be sent to a patient with multiple conditions.
Things to consider:
- A new patient must be reviewed at the time of registration.
- A new diagnosis must be reviewed at the time of diagnosis.
- Good data quality is required for new & resolved diagnoses (see here)
- The system is reliant on specific codes being added to the patient record:
'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.)
These codes will ensure patients are removed from the invite searches once their specific reviews are done (more information on this can be found in the Sending Invitations support article) - Whilst invitations are only sent annually, some conditions require more frequent review. Additional reviews should be booked at the time of the previous appointment.
- This is not an all-encompassing solution for every condition & circumstance. Clinical expertise and judgement is still required at all stages. It is the practice’s responsibility to check the reports/templates/alerts prior to commencing the LTC review process.