036 Continuity of Care (Foundry) Searches
Introduction
The Continuity of Care (Foundry) searches are designed to support practices using the Foundry RAG system to implement continuity of care. This may also support continuity of care improvement work being done as a PCN in line with the Network DES 2025/26.
The searches will provide the following information:
- Patients who have been coded with one of the Foundry RAG status codes or who may still need to be coded
- Cohorts of patients who may be appropriate for Foundry RAG coding or who may need review
- Data quality searches to identify patients who may need to be reviewed prior to coding with a Foundry RAG status
Foundry RAG Status
The Foundry searches and protocols are designed to support practices implementing the Foundry RAG status process within their organisation. Further supporting materials can be found in the Foundry Standard Operating Procedure and the Foundry Urgent Care Organisation Presentation.
Additional information on the Foundry Protocols, HP219 and HP220 can be found in our support article.
The SNOMED codes used for the Foundry RAG Status are as follows:
Status: | Code Term: | Code ID: |
Green | General health good | 135815002 |
| Amber | Chronic long term disease management required | 416239002 |
Red | Chronic long term disease management required: complex needs | 416357003 |
Status Searches
The searches in the top level folder provide a breakdown of the patients who have a Foundry RAG status coded on their record and those without any Foundry RAG Status. It then displays the cohorts of Red, Amber and Green patients according to the most recent status recorded.
Potential Cohorts
The Foundry RAG Status may be applied on a patient by patient basis or practices may wish to identify particular cohorts and apply a red, amber or green status to all patients within that cohort. If using the batch coding approach we would recommend that you start with green cohorts and then move to amber and then red to ensure the latest code on the patient's record is the most appropriate.
There are many cohorts that practices may wish to include in this process and we have tried to avoid too much duplication of searches that are already provided in other folders. In the Potential Cohorts folder you can currently find patients on a frailty register, living in a care home, currently housebound and those on the palliative care register. These are groups which have been requested by customers to assist with the continuity of care process.
Practices may also wish to review patients on various clinical registers and we would recommend our 012 Audit Ready folder and/or our 004 QOF folders of searches for a wide number of clinical registers. When considering access and continuity of care, our 035 Reasonable Adjustments Digital Flag folder of searches for a patient cohorts such as those with LD, autism, dementia or a SMI.
Data Quality
Our Data Quality searches identify a selection of patient cohorts who may need to be reviewed prior to being coded with a Foundry RAG Status. This includes patients whose latest frailty code does not match their latest frailty score and patient who have been coded with a code used by the Foundry RAG Status system prior to registering with the practice. We would recommend that any new patients who have a pre-existing Foundry RAG Status code are reviewed as practices may be using these codes in different ways or have different definitions for their continuity of care model.
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