UCL Partners have developed a series of proactive care frameworks to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, while reducing GP workload. The frameworks include atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma and COPD.
The frameworks are comprehensive and include:
- Comprehensive search tools to risk stratify patients – built for EMIS and SystmOne.
- 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.
- 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. Training includes health coaching and motivational interviewing.
- Digital and other resources that support remote management and self-management.
The frameworks are being implemented by GPs across the country, helping practices to identify who needs priority care, and those whose care can safely be delayed.
These frameworks are designed to be adapted to local context and preferences.