Enhancing Continuity of Care in Family Practice: A Case Study
The Family Practice implemented a GP reallocation tool to focus on the top 30 frequent attenders. Microteams were formed to ensure continuity of care for these patients, leading to positive outcomes such as improved access to services and patient satisfaction. The initiative was well-received, with plans to continue the program quarterly. Early successes and patient feedback highlighted the importance of maintaining a consistent healthcare provider for better outcomes.
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What did we do? The Family Practice Dr Nicola McGuinness & Kelly Williams Practice Overview No of GPs Patient Population Location CoC Approach 12 GPs c.17k with larger older population Affluent, city GP & Buddy working with cohort of Frequent Attenders February 2020
The Family Practice Ran Usual GP Reallocation Tool & selected cohort of Top 30 Frequently Attending (FA) patients Reviewed FA cohort, separating Physical, Mental Health, and those needing multiple appointments due to a recent episode CoC Patients added opportunistically by GP team but looking to move to running the Tool quarterly Using the Tool checked which GPs the patient saw most in past 12 months and noted: - Lead GP - Second GP Identification Microteams formed of Lead GP and 2nd GP. Key information on patients will be passed at lunch time meetings Circulated the patient list to the Lead GP Drafted patient letters and circulated to colleagues for comment Current patient pathway for FA reviewed. Change includes option to refer patient to social prescriber Preparation Added CoC EMIS code to the 30 patient records Amended Usual GP field on EMIS to match Lead GP for the 30 patients Set a pop up for those 30 patients to remind Reception Team these patients need CoC Pop Up Wording: Continuity of care is important for this patient. Please ensure you book the patient to: Lead GP <name> Or Second GP <name> This alert is the first alert Reception see and cannot be overridden Set up CoC appointment slots, 1 each morning and 1 each afternoon for all GPs Re-authorised prescriptions and letters so all documents will be sent to Lead GP EMIS If appointment not booked 48 hours before the appointment time, release them This can be done at same time as adding GP details to pop up. It takes a few minutes per patient to do both Staff training session on the CoC pop up reminder Posters put up in waiting room and leaflets on display Letters sent to the 30 patients the wording dependant on patient s medical history Presentation on CoC given to PPG who have supported initiative Initial staff session on why continuity matters and shared a copy of the letters being sent to patients Information
Review Early success Early success: Patient, who is not elderly but suffers with loneliness and social isolation, referred to social prescriber and is feeling better now he is connected back into the community including a lunch club Patient A Patient A: Telephoned on receipt of the letter and was very upset. Patient decided to cancel all future appointments as felt letter suggested she was wasting GP time. Later the same day, the patient telephoned again to say that having digested the contents of the letter, she now felt that seeing the same GP would be a good thing. 2 patients have told their GP they feel the project is helping them access they care they need as both view continuity of care as vital Patient B Patient B: Telephoned to say happy to be part of the pilot but would prefer one of the buddy team to be a female. The patient had been seeing a female GP but in reallocating workload their GP was changed to a male. The patient said initial reading of the letter had made her feel anxious although but having a usual GP is exactly what she would like. Going forward Going forward: Parents and children look at keeping them with same usual GP Measure the impact of the change it feels as though patients are booking less Microteam check on team approach including information sharing Rolling Programme current opportunistic identification of patients by GP Team may be replaced by running the Usual GP Reallocation Tool each quarter
Appointment Booking Patient contacts reception Pop up CoC reminder triggered on loading patient record Care Navigator looks for regular/routine slot with Lead GP or 2nd GP within next 2 weeks If no appointments available in next 2 weeks, Care Navigator will book Patient into CoC appointment slot If there is no CoC appointment slot available patient is asked to call again
Resource: Patient Letters FREQUENT ATTENDERS PATIENT LETTER (MUS) Dear .. We are continually looking at how we improve services for all our patients and we have identified that you are among a small number of patients at the practice who are being seen on a very frequent basis. In the past 12 months you have visited the surgery x times for appointments. The frequency of your attendances suggests to us that we are not meeting your needs, and that means you are having to visit the surgery more. While some chronic illnesses need regular monitoring, often when a patient is frequently seeing their GP it suggests something different is needed. For example, patients may benefit from being linked to other organisations that are able to help you to remain independent and manage your life, including your medical problems, more confidently. To help us to provide services that meet the needs of all patients, we are putting a new process in place. This will start from <date>. From that date, we would ask that you: Always try to see your usual/lead GP who is Dr X . If they are not available you have been allocated Dr X who will also be fully aware of your case and care. Only make appointments at the practice when you have a medical need. Please do not book just in case appointments as this will mean a patient who does need an appointment may not be seen. Duty Doctor appointments are available for patients with urgent needs. Please do not book into the Duty Doctor slots for routine or ongoing issues, even if it is your GP on duty, as it may mean a patient with urgent issues is not seen. Our Reception Staff have been re-trained as Care Navigators. This means they are able to discuss with you the most appropriate appointment type and to work with you to guide you to the most appropriate course of action. We very much appreciate your support with this initiative. We anticipate that by tackling this together we can meet your needs better and in turn give you greater independence and ability to take control of your health. If you would like to discuss this initiative with your GP, please contact the Reception Desk who will arrange for your GP to give you a call. Yours etc FREQUENT ATTENDERS (MH/PERSONALITY DISORDERS) PATIENT LETTER Dear .. Continuity of care means patients seeing the same GP, or the same members of a clinical team. There is a growing body of evidence showing continuity is beneficial to both patients and GPs. When the GP-Patient relationship is stronger, patients feel more at ease, more able to disclose sensitive information, more likely to follow advice, and less likely to be admitted to hospital. The Family Practice is introducing continuity of care from <date>. This will mean some minor changes to the booking of appointments, and we would ask for your support: Always try to see your usual GP who is Dr X . If they are not available you have been allocated Dr X who will also be fully aware of your case and care. Unless it is urgent, please do not book into the Duty Doctor slot for routine or ongoing issues even if it is your Usual GP on duty. Please only make appointments at the practice when you have a medical need. Our Reception Staff have been re-trained as Care Navigators. This means they guide and support you on the most appropriate appointment type and course of action. We very much appreciate your support with this initiative. We anticipate that by tackling this together we can meet your needs better and in turn give you greater independence and ability to take control of your health. If you would like to discuss this initiative with your GP, please contact the Reception Desk who will arrange for your GP to give you a call. Yours etc
Continuity of Care Project Manager: Continuity of Care Project Manager: Julia.Martineau@onecare.org.uk Julia.Martineau@onecare.org.uk
