Using A Long-Term Conditions Register To Help Care Planning At Weybridge PCT
We worked with Weybridge PCT to support three pilot practices in establishing a long-term conditions register in order to support long term care planning.
We devised searches using the existing GP clinical system and integrated data on prescribing costs over a 12-month period for each patient and PARR scores (Patients At Risk of Re-admission) data where available.
The resulting data was formatted into a simple and workable spreadsheets containing all patients with multiple diseases (as specified by the PCC).
Outcomes:
- By combining the PARR Scores with the number of disease registers, it was possible to divide the large number of patients initially identified into manageable cohorts.
- A group of patients were identified as a priority for review as they were found to be on multiple disease registers.
- The spreadsheets helped with care planning to reduce the risk of hospital re-admittance.
The data provided by the audit process gave clinicians a holistic patient profile that enabled informed clinical interventions.
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