Clinical review and recall setting

Clinical review and recall setting

Information within this training package is colour coded:  

Blue is for information and includes hints and tips                                                                                                                                                                                                                 
Orange is an action that is required                                                                                                                                                                                                                                         
Yellow is resource that you can use to send internal communications to others within your practice                                                                                                                               
Red is a key message that must not be forgotten or ignored                                                                                                                                                                                                

Introduction

The principle behind the system is that the clinicians retain complete control over the “recall loop”.                                                                                                                               
Once they are satisfied that all elements of care have been attended to, clinicians need to code:                                                                                                                                                                       
    • “Chronic disease annual review”  (Concept ID 816421000000101, Description ID 2127501000000113)

  • To help with this we have developed OneRecall Alert for the Zap box with a linked template to update review status

If you haven't already watched the introductory video for clinicians we would suggest doing this first:                                                                                                                           


OneRecall Alert for Zap box
  • This appears for anyone who is eligible for a Chronic Disease Annual Review - whether QOF related or otherwise. 

    • If the review is overdue, this appears as a red ‘Zap Alert’ entry near the top of the alert box.

    • If the review is not-overdue, but there is an opportunity to perform an early review, the alert appears as a grey ‘Zap Alert’ entry near the bottom of the alert box.

    • The alert is designated as overdue if the person has been sent an invitation for a chronic disease annual review but not yet had a review coded since. 

  • OneRecall is an information panel designed to complement the information delivered in our OneResults and OneMonitoring panels.  

  • Double-clicking on the alert will launch the OneRecall template

  • See our supporting video for more information and the end of the article for more screenshot examples

Anatomy of OneRecall Zap alert

Alerts are grey if up to date, and red if overdue so you can quickly see the recall status without even hovering over the alert                                                                              

 


OneRecall template

  • The template is launched by double clicking on the OneRecall zap alertt.

  • This template needs to be run by the clinician to close off the review.  

  • It provides a consistent and easy way to apply the recall-loop closing code

    • “Chronic disease annual review”  (Concept ID 816421000000101, Description ID 2127501000000113)

  • Engaging with the template will need specific training for all your clinical staff, to prevent the continued issuing of reminders.

  • We suggest the template is best launched at the end of a consultation, once the planning ahead section has been considered.  

  • The template gives a clear overview of the patient’s place in the recall cycle and the opportunity to record updates and future planning.

  • OneRecall includes a COVID-19 catch up panel that can be used 

Anatomy of OneRecall Template

COVID-19 Catch-up Panel


This will only show when when the the following code has been used in the record 

  • Provision of advice, assessment or treatment limited due to COVID-19 pandemic

    • Concept ID: 1321171000000106

    • Description ID: 2827521000000112

And will remain until this code has been entered into the record

  • Proactive care review

    • Concept ID: 11932131000006101

    • Description ID: 11932131000006117


The COVID-19 Catch-up panel allow the user to understand when and why care was limited by the pandemic, to review the notes for outstanding tasks and to close the episode off by coding a Proactive care review.


Recall Status Information Panel

Under normal circumstances, this is the panel that appears at the top of the template to help manage recall.  It is a summary of where the patient is up to with recall procedures:


  • There is an opportunity to code a verbal QOF invitation in the last check box.

Code the Review, an Opt-Out, Exception Report or Medication Review                                                                                                                                    

The most important code on the template is the code that closes the review.  For most users, this is the only box that needs ticking on this panel.  Clinicians need to know how to find it and when to use it. 

The other boxes are for coding the patient’s wishes around opting out and exception reporting.  


Planning Ahead - IMPORTANT                                                                                                                                                                                                       

This is a very important panel on the template.  It allows the clinician to judge when the next review is likely to happen and to make plans that can bring this forwards. 

  • By default, OneRecall aims to call people annually in their month of birth. Additionally the clinician has the option of setting an earlier date by picking a month.  

    • Note, when an Annual Review has been coded, this always prevents further invitations within the next 3 months, even if a diary entry has been set in that 3 month window.

    • This also means that a person born in (for example) June, who had an opportunistic review coded in the April before, will not appear in June’s recall search.  Potentially that person will wait until June of the following year for another invitation.  In this situation, it may be appropriate to set a diary date for an invitation this December.

    • See the end of the document for some patient recall scenario calendars


  • The diary date is for an invitation letter:

    • QOF (Quality and Outcomes Framework) quality indicator-related care invitation  Concept ID: 1109921000000106

Explanation of Coding and the OneRecall System

Recall can be a complicated process, there are a number of codes that help it to run and you may not have this handbook to hand, so we have included an explanation panel to advise users about the system.  This panel also captures a code to track when the template has been used.  



OneRecall Zap alert - examples

Who does OneRecall Capture?

The main search engine for your recall patients: Search R) RECALL MASTER SEARCH - Recall Needed 

It is designed to identify all of those patients you would normally aim to review at least annually because of the conditions they have or the drugs they are prescribed. 

IMPORTANT: It does not deal with high risk drug monitoring such as Lithium and DMARDs.  We have a separate weekly search product for this.  

It also picks out certain predefined diary entries that may have been used to plan care in those same conditions.  If you are a PrimaryCare Pathways subscriber you may use these diary codes in our other resources such as the OneTemplate. 

Please do not edit these searches as we cannot guarantee their functionality if errors are made. 

Do feedback to us at TheTeam@primarycareit.co.uk if you have feedback, ideas and suggestions.


Rule(s)

Situation

1

Commonly used diary entries, including from OneTemplate and for additional recalls

2

Diabetes

3

Ischaemic Heart Disease

4

Heart Failure

5,6

Stroke and TIA, including Haemorrhagic Stroke

7

Hypertension

8

COPD

9

Asthma

10

Dementia

11

Atrial Fibrillation

12

Peripheral Arterial Disease

13

Rheumatoid Arthritis

14, 15

Osteoporosis

16, 17,18

Pre-diabetes / At risk of diabetes

19, 20

Severe Mental Health / Lithium (for annual care review)

21

Chronic Kidney Disease

22

Epilepsy

23

Learning Disabilities

24

Palliative Care (Not Red / Amber; Days / Weeks of life) 

25, 26, 27

Depression, including review after initial diagnosis

28, 29

Hypothyroidism

30

Cancer

Recall Scenario Calendars

It is hard to encapsulate all scenarios, but here are some common examples of how a patient mat engage with the OneRecall system, all with different months of birth.  



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