CEG Risk Stratification: Triple Aim, CVD-APL, AF-APL and T2 diabetes APL tools.
Covid-19 has placed an emphasis on the need to optimize management of long-term conditions
- Prioritise risk groups
- Rapid virtual review of needs relevant to different staff - HCAs, pharmacists, nurse and GPs
- Enable care closer to home and self-management
CEG provides tools to stratify patient risks and support ongoing management. The CEG APL-tools provide a flexible ‘front-end’ so that the practice can select which risks to prioritise.
What is more important however, is “what happens next” for any selected patient. For example, how will HCAs help management for low risk patients? How should GPs and pharmacists best optimise BP control.
CEG has developed a range of educational and support utilities available on our website to support management. CEG will also provide educational support for CVD and AF optimization.
CEG has developed the APL-tools that flexibly stratify patient risks and ALSO display the individual patient characteristics so that staff can rapidly review their requirements. This highlights both clinical needs – high BP, low eGFR etc – as well as social needs – learning disability, palliative care and housebound etc. and also interacting medicines.
- The AF-APL tool is available for EMIS, SystmOne and Vision
- The T2 Diabetes and CVD APL tools are available at present only for EMIS
- The asthma prescribing tool to reduce hospital admission is also available Request them from CEG here
CEG has a range of support materials available on the website
Guidelines for Hypertension BP control; CVD high intensity statins and AF anticoagulation and reduced bleeding.
- Asthma tools explained at CEG Real Health Respiratory or CEG Youtube Video on Asthma
- CVD Tools videos are available at CEG APL Tools page
- CVD guidelines and additional educational materials are available at CEG REAL-Health Resources
UCLP Risk Stratification Frameworks
The UCLP frameworks will help practices deliver proactive care to patients with long term conditions in the new world of primary care post COVID where as much care as possible needs to be delivered remotely. The frameworks have been developed by GPs and pharmacists with patient and public support.
The frameworks include search and stratification tools that have been built by CEG for EMIS and SystmOne. They stratify patients into high, medium or low risk or priority cohorts based on clinical and other criteria. This allows practices to prioritise which patients need to be reviewed early and who can safely be phased for later review.
The UCLP search tools are accompanied by extensive resources that include:
- Pathways that maximise use of remote care and utilise the wider workforce including pharmacists and HCAs/link workers etc
- Scripts and protocols to help these staff to deliver support for education, self-management and lifestyle change
- Training that includes motivational interview and health coaching techniques
- A suite of digital and other resources
These resources are all free and can be accessed here via the UCLPartners website.
CEG Publication on East London Primary Care Experience of the First COVID Wave
The CEG paper on the east London primary care experience of the first COVID wave is now online in the British Journal of General Practice.
You can read it here: https://bjgp.org/content/early/2020/09/07/bjgp20X712601
CEG would like to give a big thanks to all the practices in inner east London for contributing their data. The publication could not be timelier, just as we risk going into a second wave. The contribution of primary care to managing the second wave will no doubt be very important, as the effectiveness of centrally organised contact tracing is being challenged. We were seeing three times as many cases in general practice than were being picked up by national testing. We also demonstrated the high risk to BAME patients in contracting COVID and how multimorbidity and obesity, though important, do not explain that risk.
The paper has had some impact, being reported on in various outlets including the Times, the Mail, and on TV, and in GP magazine.
Suspected COVID-19 in Primary Care: How GP Records Contribute to Understanding Differences in Prevalence by Ethnicity.
Also see our Twitter for more news & updates
Our working arrangements during the COVID-19 pandemic
In light of Covid-19 the CEG team will be working from home from Thursday 19th March. We are reviewing options to reduce face to face contacts and travel.
Tele-support We will support practices via e-mail and could also offer Zoom or Skype.
Direct log-in to practices We will ask practices to provide us with a login where needed so we can review and address any problems. Practices will still need to approve this individually and monitor as they would any other external contractor.
We endeavour to maintain normal levels of service during this time and will continue to deliver our contracted dashboards which will be hosted in CEG website. We will be updating templates/protocols/documents as required and will be maintaining our suite of searches.
East London Community Renal Clinic featured in NHS Long Term Plan launched on 7th January 2019
The latest NHS Long Term Plan was launched on 7 January. It is an ambitious vision to improve NHS care with an increased focus on prevention and digital solutions.
The innovative east London Community Renal Clinic, developed jointly by CCGs, the Clinical Effectiveness Group and Barts Renal department is featured as a case study in the opening chapter: “A new service model for the 21st century”.
GPs at the DeepEnd
The Deep End Project started in Glasgow with Prof Graham Watt who got the 100 most deprived GP practices in Scotland to regular meetings to address the particular needs of their disadvantaged patients.
GPs at the Deep End have been highly successful in advocating for their patients and campaigning for services and resources to meet the increased needs of practice populations in areas of deprivation.
The Deep End model has since spread throughout the world with practices in areas of concentrated disadvantage grouping together to share ideas, get involved in education and training for the specific challenges of deprivation and expand the field of research of primary care's role in addressing the causes and consequences of health inequalities. There are now DeepEnd projects in Dublin, Manchester, Humberside, Sheffield and elsewhere
A recent conference held in Glasgow in 2019 was inspirational for those that attended – you can view the presentations on YouTube and also download the presenters slides from this weblink.
The presentation by Austin O’ Carroll was particularly memorable and highly recommended!
Download Presenter slides here
Watch Presentation on YouTube here
There is also a book edited by Prof Watt including contributions by a number of the speakers – again highly recommended reading.
Newham, Tower Hamlets, City and Hackney Prescribing Improvement (31/8/2018)
CEG and prescribing advisors in Newham, City and Hackney and Tower Hamlets CCGs have promoted medicines optimisation and safety for a number of different medicines since 2015. In the year 2017-18 there was improvement in some measures but no change in others.
IMPROVEMENT % change and latest 2018 (%)
Use of high intensity statins (atrovastatin 40mg or 80mg) in people with CHD, stroke/TIA, PAD, T2 diabetes.
This averages 41% across all 3 CCGs and increased by 2.3% 2017-18.
2018 TH +2% (46.4%) C&H +4% (46.7%) NH +1% (33.0%)
Reduced ICS in mild/moderate COPD
This average 38% across all 3 CCGs and reduced by 3.7% with marked differences between CCGs:
2018 TH -7% (32.0%) C&H -3% (35.0%) NH -1% (47.1%)
NO IMPORTANT REDUCTION
8% of people with CVD* still prescribed NSAIDs *(IHD,stroke/TIA, PAD,HF,CKD)
11% of people with Asthma prescribed salbutamol >12 and ICS<6 inhalers
– possibly reduced by 2% in C&H.
6% TH, 9% C&H and NH: % Long acting analogue Insulin in people with T2 diabetes