The Covid-19 pandemic caused massive disruption to primary care. Patients with long term conditions such as diabetes and hypertension could have their conditions exacerbated, which could add further waves of demand for unscheduled care in primary care, emergency and hospital admissions. In response, UCLPartners developed a series of Proactive Care Frameworks for the management of long term conditions in this new world, including atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma, COPD, and severe mental illness.
The frameworks are made up of five key elements:
- A comprehensive set of patient search and stratification tools built for EMIS and SystmOne
- A selection of appropriate pathways that prioritise patients for follow up, support remote delivery of care, and identify what elements of long-term condition care can be delivered by staff such as Health Care Assistants and link workers
- Straightforward scripts and protocols to guide Health Care Assistants and others in their consultations
- Training for staff to deliver education, self-management support and brief interventions, including health coaching and motivational interviewing and digital
- and other resources that support remote management and self-management.
The frameworks particularly emphasise working at scale by:
- enabling practices to prioritise clinical activity by stratifying patients who are at highest risk
- deploying the wider workforce to reduce the workload for GPs
- and improving the personalised care offer for patients.
They are also designed to be adaptable to a variety of different local contexts and preferences to ensure that they are applicable on a national scale.