OnePriority Handbook

OnePriority Handbook

OnePriority Handbook


Introduction 2

Background 2

Personalisation 2

OneRecall Subscribers 2

Feedback 2

Disclaimer 2

Installing the Searches 3

Subscriber Install 3

Non Subscriber Install 4

How to use the package 7

Run the searches 7

Use the Results 7

Basic Search Detail 9

H01) RECALL - HOUSEBOUND AND CARE HOMES 9

Localise Your Care Homes 9

Adding Additional Care Homes 10

P01) RECALL - PRIORITY BASE SEARCHES 10

R01) RECALL - ALL DUE DISEASE REVIEW BASE SEARCHES 11

R02) RECALL - PRIORITY DISEASE SEARCHES 12

R03) RECALL - GROUPED DISEASE SEARCHES 13

R04) RECALL - GROUPED PRIORITY DISEASE SEARCHES 13

Advanced Search Detail 14

Default Configuration 14

Agreed Priority Indicators 14

Social Priorities 15

For Subscribers 16

REC002 Recall Closing Support (Alert) 16

Anatomy of REC002 Recall Support (Alert) 16

REC003 Recall Support (Template) 17

Anatomy of REC003 Recall Support (Template) 17

COVID-19 Catch-up Panel 17

Introduction

Background

We have had a health care year like no other, one unlike we had planned for or expected to work through.  Coronavirus has meant we have had to deal with ever changing demands, working patterns and vastly different work and personal priorities.  One of our main roles in society is long term condition care and the manners in which we are measured on it, has been paused.  At the time of writing there is uncertainty about the contractual and financial implications on practices and an understanding that we cannot deliver the full year-of-care to all.  Most Primary Care teams have quickly acknowledged the need to catch up on ‘routine’ care since we are beginning to see that some patients are showing signs of suffering.  


OnePriority aims to prioritise the Long Term Condition recall for your practice population, based on an array of over 100 (check number of codes used) clinical and social clues that are already coded in their medical records. It aims to provide a systematic approach to identifying those patients by applying the kinds of rules that make logical sense to a primary care clinician.  It is built with the firm principle that no one is excluded from care but that some patients may benefit from being identified sooner.


🎥A video overview of OnePriority can be viewed here https://vimeo.com/453923078 

Personalisation

Our standard “out-of-the-box” deployment provides practices with a balance of inclusion versus manageable workload and priority.  However, OnePriority is built in such a way that, once practices understand how it works, they can decide on their own thresholds and rules to apply.  You may also decide on new areas of priority and, because of the way we’ve built it, these can be added in and the system improved.  We can help you do this with our training materials and The Team are on hand if you get stuck. 

OneRecall Subscribers

Some practices had just begun to use our OneRecall and OneTemplate packages when the Coronavirus pandemic began.  OnePriority can easily be used as a standalone population identification system, or it can be used to feed into resources in your OneRecall and OneTemplate packages, using the same diary codes as these systems and the same codes to close off a review and plan future contacts.    

Feedback

As ever, we really value your feedback on our tools, both when things aren’t working as expected and with development ideas.  Please contact the team on TheTeam@primarycareit.co.uk


Include your site (cdb) number and, if you are a subscriber to our tools and hold a Data Sharing Agreement with us, the EMIS number for the patient.  If you are at all unsure about our role in processing your patient data then ask your Data Protection Officer or Caldicott Guardian first.

Disclaimer

We are continually developing and improving our resources.  Screenshots and videos are accurate at the time of publishing but may not be an accurate representation of the latest version of the resource. 

This is a new resource and we would value any ideas, especially clinical ones, that may improve the package.

Installing the Searches

OnePriority is a group of searches and reports that help you find your patients.  Some searches are layered on top of other more basic ones in a modular way.  They can be run as they are, or tweaked and amended to suit your population’s needs.

A video overview of OnePriority can be viewed here https://vimeo.com/453923078 

Subscriber Install

If you are a subscriber we will update your search folder for you.  You will see a new folder in your PrimaryCareIT Search folder in the Population Reporting module of EMIS called OnePriority.  

Non Subscriber Install

If you are not a subscriber then we will make an xml file available to you that contains the OnePriority folder.

Import this to your 


  1. Click on the EMIS button on the top left of your EMIS screen.

  2. Click on reporting

  3. Click on population reporting

On the following screen:

  1. Click on the name of your organisation

  2. Click add

  3. Select and click folder


This will display the following box:


We suggest you call this Primary Care IT and use it to house any resources you download from us - enter your chosen name and click ok.

  1. Next, find the PrimaryCareIT folder you have created and click on it so it is highlighted in light blue (you may need to scroll down - folders are displayed in alphabetical order)

  2. Click on import on the top bar

The following window will display, click on the three red dots highlighted in the top right hand corner:


Now you need to locate the xml file OnePRIORITY.xml and select this in the file browser that now shows and then click open:

You will now see the EMIS window displaying the searches similar to below, click ok and you've imported all the searches!

How to use the package

Run the searches

This will force all of the sub-searches in the package to run in the correct order.  

There are a lot of searches and some of them are complicated.  It may take 10-15 minutes for them all to complete so grab a coffee ☕

Use the Results

  • Go to Folder R04) RECALL - GROUPED PRIORITY SEARCHES 

  • Check that all of the searches have a Population Count recorded against them.  If any are still “Queued” then wait a while longer (you need a bigger coffee cup). 

  • Begin working from the patient lists there.  You can run an auto-report if you wish to produce a list.

    • Give clinicians time to look at these disease lists. 

    • Make sure that they know that these patients have been identified as a priority.

    • Ask them to arrange those necessary clinical tests and enquiries, using local solutions.  This may include services such as 

      • Video consulting to complete care templates (such as our OneTemplate)

      • Home Blood Pressure monitoring

      • Drive through phlebotomy

      • District Nursing Services

      • Hub Health Care Assistants

IMPORTANT

  • Code the review using one of the following codes to remove them from further search runs.

    • Chronic disease annual review 

(Concept ID 816421000000101, Description ID 2127501000000113)

  • Deleted from recall-not wanted

  • Deleted from recall-not appropriate


  • If you want to check why the patient has been identified as a priority, navigate to 

    • Folder P01) > Search P00c) Agreed Priority Indicators 3+

    • The “Population Included” tab in the bottom panel

    • Find and right mouse click on the the name of the patient

    • Click ‘Check patient” and the following panel appears, telling you which searches they were included in.  You may need to scroll to see them all (as in this example).


Basic Search Detail

  • There are 6 folders within the package. 

  • Skip to the good bit… we recommend you use folder R04) - RECALL GROUPED PRIORITY SEARCHES as your worklist for planning the priority recall of patients this year. 

H01) RECALL - HOUSEBOUND AND CARE HOMES

  • This folder contains searches that allow you to identify the care homes and other institutions you care for.  

  • This folder contains searches that need to be personalised for your practice if you want the results later on to better reflect the workload and allow you to direct recall tasks to community services.

  • It also contains searches that help to identify if a patient is already on the Community Nursing Caseload.

Localise Your Care Homes

Double click on any of the rules noted with Postcode and Number & Street rules:

Then double click on each of the elements and add in the details for one care home:


Use one rule for each care home, completing both Postcode and Number & Street

Adding Additional Care Homes

More rules can be added if you have more than 4 facilities by clicking on one of the rules and pressing copy and paste in the top menu bar



If you do this, make sure you adjust the rules for passing and failing as shown below

From:

To:


P01) RECALL - PRIORITY BASE SEARCHES

  • This is probably the most important folder in the package.

  • It contains many subsearches that individually pick out areas of priority.

  • It also contains searches that count the number of priorities found.

  • Over 100 coded situations are considered and this can be later added to as needed.

  • Each of these searches are used later to help the disease searches identify higher priority situations.


Some examples of priority situations include:

  • People who live alone

  • BAME ethnicity

  • Poor angina control

  • No face-to-face consultations in the past 18 months

  • High Hba1c levels, significantly above QOF thresholds

  • Food bank use

  • Social Service involvement and Safeguarding concerns

  • High BP levels, significantly above NICE targets

  • Recent myocardial infarction

  • Low Patient Activation Measure (PAM) scores

  • High rescue inhaler prescription ordering

  • Recent indications of suicide risks


  • R01) RECALL - ALL DUE DISEASE REVIEW BASE SEARCHES

    • Each search looks for the patients who have that condition

    • Who are not coded as being in the last days or weeks of life

    • Who have not been coded with

      • Deleted from recall-not wanted

      • Deleted from recall-not appropriate

      • A recent Chronic disease annual review 

    (Concept ID 816421000000101, Description ID 2127501000000113)

    R02) RECALL - PRIORITY DISEASE SEARCHES

    • This folder may be used as your final search folder if you wish to tackle the recall of patients on a disease-by-disease basis.

    • Each of the searches in the previous folder has a priority search run against it, to give a smaller number of patients with current high priority situations.

    • Be default the priority search used is P00c) Agreed Priority Indicators 3+ (found in folder P01)

    R03) RECALL - GROUPED DISEASE SEARCHES

    • This folder aims to draw together logical disease groups to help manage the workflow at the practice.

    • None of these groups have been prioritised, so in that respect they are similar to folder R01)

    • G01) includes patients who have a vascular condition such as IHD, CVD, AF, CKD etc

    • G02) includes patients with COPD and Asthma

    • G03) includes patients with Diabetes or Non-Diabetic Hyperglycaemia

    • G04) includes patients who are not found in any of the above but who have a Long Term Condition

    • G05) includes patients who have 5 or more conditions, whether or not in they are in G01)-G04)

    R04) RECALL - GROUPED PRIORITY DISEASE SEARCHES

    Your main search folder

    • Finally we have the search folder that we recommend you to use for most of the planning process this year.  

    • It both collects the disease groups together and cross references the chosen priority search.

    • The priority search used is P00c) Agreed Priority Indicators 3+ (found in folder P01)

    • It helps you work out who you may expect to attend the medical centre and who needs community team support.  It also helps you work out who may already be on community team case loads. 

    • Codes used to control this are:

    • Housebound

  • No longer housebound 

  • District nurse attends

  • Temporarily housebound

  • District nurse involv.stopped

  • District nurse involvement stopped



  • Advanced Search Detail

    You can amend the results of the priority searches by changing the priority search that is used against each of the searches in folders

    • R02) RECALL - PRIORITY DISEASE SEARCHES, and

    • R04) RECALL - GROUPED PRIORITY DISEASE SEARCHES


    You may wish to do this in the following scenarios:

    1. Where the number of patients returned by the default configuration is too big for your team to initially manage.

    2. Where the number of patients returned by the default configuration is too small to feel adequate to your clinical team.

    3. Where you have managed the reviews for most of the patients returned from the default configuration.

    Default Configuration

    Agreed Priority Indicators

    • At the top of folder P01) RECALL - PRIORITY BASE SEARCHES there are 5 searches, each with different thresholds.

    • These are the key searches used to prioritise all the other disease searches and you should agree as a team that they are appropriate for your population and clinical environment.  

    • By default we use search P00c) Agreed Priority Indicators 3+ to cross check against the disease searches.  That means at least 3 priority situations have been found in the patient’s records. 

    • You can change the default configuration to one of the other 4 searches to broaden or narrow the target population.  

    • Do this by editing the Disease Priority Search, for example, here we are going to edit the 

    GP02)  Respiratory Grouped Priority Search



    Social Priorities

    • Social Priorities are used throughout the package.  Some of these are noted above.  

    • Broadly they include codes related to non medical concerns such as social service involvement, lack of engagement, food bank use, severe mental illness indicators and more. 

    • We have then used a scoring system in searches P01) - P04) to look for 1, 2, 3, and 4 or more of these.

    • The default package uses search P02) Social Priority Indicators - 2+ within the Agreed Priority Indicator Searches (above), but you can change this if you wish to make the search results broader or narrower in the same way as above.

    For Subscribers

    REC002 Recall Closing Support (Alert)

    • 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. 

    • REC002 is an information panel designed to complement the information delivered in our OneResults and OneMonitoring panels.  

    • Double-clicking on the alert will launch REC003 Recall Support (Template)

    • See our supporting video for more information and the Appendix for more screenshot examples

    Anatomy of REC002 Recall Support (Alert)

     

    REC003 Recall Support (Template)

    • The template is launched by double clicking on the REC002 Recall Support (Alert) line. 

    • 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.

    • REC003 is best launched at the end of a consultation, once the planning ahead section has been considered.  

    • REC003 gives a clear overview of the patient’s place in the recall cycle and the opportunity to record updates and future planning.

    • REC003 includes a COVID-19 catch up panel that can be used 

    Anatomy of REC003 Recall Support (Template)

    COVID-19 Catch-up Panel

    Appears 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

    Until this code has been entered into the record

    • Proactive care review

      • Concept ID: 11932131000006101

      • Description ID: 11932131000006117


    The COVID-19 Catch-up panel allows 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.



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