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Improving care for patients with long-term conditions

Dr Helen Coundon explains how her practice developed a new model for managing long-term conditions, which involves the whole practice team.

The new system links clinical medication review with the LTC review process (Picture: iStock)
The new system links clinical medication review with the LTC review process (Picture: iStock)

The long term economic burden on health and social care as people live longer with increasingly complex conditions is well documented. Long-term conditions (LTCs) account for 70% of NHS spend.  

At Monkseaton Medical Centre in Tyne and Wear we have developed and implemented a fully integrated, multidisciplinary model for management of LTCs. This involves health care assistants (HCAs), practice nurses, practice and community pharmacists, receptionists and GPs.

The initiative delivers improved quality of care and helps prevent hospital admission via an innovative, efficient model for LTC monitoring review and medication supply to support patient care and medicines optimisation.

Why we changed things

The previous system for managing patients with LTCs was disorganised and fragmented. Patients were invited by letter for their annual LTC review appointment but many patients ignored these letters and were not subsequently followed up, leading to increased risk of re-admission and adverse effects from medication. Medication review was a separate process and was not linked with repeat prescribing supply.  

What did we do?

A new pro-active system of inviting patients for LTC reviews was implemented. Receptionists now telephone patients to book their annual LTC appointment with the HCA. Standard protocols and templates have been implemented to ensure governance and a GP is always available.  

Patients are advised to call the surgery for their results; routine follow-up appointments are no longer required. All LTC results are reviewed and filed by the practice pharmacist. Normal results are given to the patients by phone by the receptionist.

Meanwhile, the pharmacist documents an action plan for borderline/abnormal results and orders any further tests, for example fasting blood glucose and ferritin, folate and B12.

Additional blood results are followed up by the pharmacist and prescriptions issued where required. QRisk is calculated and at-risk patients are contacted by the pharmacist and offered the opportunity to discuss the options using shared decision making, statins may be prescribed.    

Medication reviews

With the increase in evidence-based prescribing patients with long term conditions face an ever increasing medication burden and poly-pharmacy and this new system links clinical medication review with the LTC review process to ensure medicines optimisation.

The pharmacist checks adherence and housekeeping in order to reduce waste and minimise preventable medicines-related problems, which may lead to adverse effects and/or readmission. The medication review is documented and the medication is re-authorised. If the patient is stable on their medication a repeat dispensing prescription is issued for up to 10 months supply.

We have a close working relationship with the community pharmacists locally and when the penultimate repeat dispensing prescription is supplied the patient is reminded to request a new supply from the GP and at the same time is offered a medicines use review (MUR) by the community pharmacist.

The MUR supports adherence and medicines optimisation and is reported back to the practice pharmacist.

The need for clinical medication review to optimise therapy is well recognised and this integrated model for LTC ensures that review of the patient’s condition is embedded with medication review, repeat medication supply and follow up ensuring high quality, cost-effective care.

Monkseaton Medical Centre was one of the finalists in the Improving Quality and Productivity category of the 2014 GP Enterprise Awards. You can read more about the awards here.

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