Grange Road Practice Continuity of Care Project
Grange Road Practice implemented a Continuity of Care Project to address patient needs effectively. By identifying a cohort of frequently attending patients, updating Usual GP fields, and establishing Microteams, they aimed to improve patient care. Insights from the data revealed patterns in patient visits, high continuity for certain groups, and the importance of maintaining consistent care for better outcomes.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
E N D
Presentation Transcript
What did we do? Grange Road Practice Dr Douglas Redpath Owen Thomas Emily Nichols Practice Overview List size: c11,000 patients 11 GPs City, deprived area Approach: Update and maintain Usual GP field Focus: people who Attend Frequently Microteams
Grange Road Identification Identification Ran the Usual GP Reallocation Tool. Identified patients who had >25 GP appointments in the previous 12 months. This gave a cohort of 40 patients. Held Clinical Meeting to review cohort with our GP Team to decide who was suitable and who should be exempt from project. Patients were split: people who attend frequently & people with mental health challenges who attend frequently. To maintain cohort of 40 patients, all exempt patients were replaced with another person who attended frequently. Preparation Preparation Each GP was asked to decide on the action needed for their patients in the cohort. The GP making the decision was the GP who had seen the patient the most over the past 12 months. See Resources for how this data was collected. Microteams the practice had established GP & Buddy teams prior to this project. There are 4 Microteams of Usual GP and GP Buddy and a fifth Microteam of Usual GP and 2 GP Buddies. Information was shared through catch up at coffee breaks. Although there was a system in place, the project has given continuity much more of a push from all GPs to ensure going to usual GP then buddy is standard. Patient Cohort CoC of care added together with a Pop Up Reminders. The pop up was added individually to each patient record in the cohort and gives GP recommendations for the patient so Reception know what to offer the patient. All Patients At the Reception desk patients are asked for their Usual GP. If patients are unsure, Team checks recent consultations and updates field if needed. This is done for both urgent and routine appointments. EMIS EMIS Information Information Introduction to Continuity of Care Project for whole practice team (see Resource Toolkit). Reception Team Training - Continuity is regular item for monthly team meetings - Staff awareness to check Usual GP and amend - Staff awareness of cohort, pop ups and letters - Registration: patients calling for first appt are put with their named GP, reception explain this is important. Patient letters sent (see later in this document) . Welcome message on phone to remind patients continuity is important. My Care Patient Leaflets, Poster and Animation displayed in Reception.
What did the data tell us? The Usual GP Reallocation data gave us some insights . Patients Patients 8% of our patients visited us 9 or more times in the past 12 months; And used 27% of total appointments. Almost 70% of our patients had visited us at least once in the past 12 months. We drilled into the Frequently Attending (FA) We drilled into the Frequently Attending (FA) cohort to identify patterns, looking at: cohort to identify patterns, looking at: Mental health or physical health? Appointment types - are they booking Same Day? How do they book? Who do they see (usual GP or are they going round the whole team)? GPs GPs 2 of our GPs had a higher number of patients who were frequently attending (attended 9 or more times in a year). We noticed some patients who attend frequently get particularly high continuity, e.g. drug users. These patients provided an opportunity for us to learn. We have explored why that is and we anticipate our approach will help redress the balance of work across the GP Team.
Why did we join? Continuity of care is important to GPs at Grange Road and to our patients Waiting Room Interviews Waiting Room Interviews GP Patient Survey Results 2019 GP Patient Survey Results 2019 A small sample of patients in the waiting room were asked for their views. Most reported they did not think it was acceptable to wait for a Routine Appointment. However, many patients said they would wait for a week to see their Usual GP supporting our view on the importance of continuity of care. According to the respondents, we are just above average so there is room to improve continuity of care.
Letters Resources: Letter to frequently attending mental health patients Letter to frequently attending patients Grange Road Surgery Grange Road Surgery Bishopsworth, Bristol BS13 8LD Tel: 0117 9644343 Drs Douglas Redpath, Patricia O Neill, Rachel Grech, Ruth Knight, Rebecca Collis, Mick Chimenti Clara Dormehl, Josh Allerton, Andy Lees Bishopsworth, Bristol BS13 8LD Tel: 0117 9644343 Drs Douglas Redpath, Patricia O Neill, Rachel Grech, Ruth Knight, Rebecca Collis, Mick Chimenti Clara Dormehl, Josh Allerton, Andy Lees GP Decision Action Sheet - EMILY Telephone answering/holding message script: <date> 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. Grange Road Surgery is introducing continuity of care. This will mean some minor changes to the booking of appointments, and we would ask for your support: i) Always try to see your usual GP who is Dr. ii) Unless it is urgent, please do not book into any slot for routine or ongoing issues even if it is your Usual GP on duty. iii) Please only make appointments at the practice when you have a medical need. iv) 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. v) You may be offered a telephone advice appointment rather than a face to face appointment. 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 sincerely Partners Grange Road Surgery <date> 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. 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. To help us to provide services that meet the needs of our patients, we are putting a new process in place. This includes: i) Always try to see your usual GP who is Dr. ii) 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. iii) Same day appointments are available for patients with urgent needs. Please do not book into the same day slots for routine or ongoing issues, as it may mean a patient with urgent issues is not seen. iv) You may be offered a telephone advice appointment rather than a face to face appointment. v) Our Reception Staff have been 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 sincerely Partners Grange Road Surgery Continuity of care is extremely important so extremely important so please try and book in please try and book in with your regular GP with your regular GP when possible . when possible . of care is Response: 2 patients were initially resistant to telephone triage
Appointment Booking Patient contacts Reception Team to book an appointment. Reception Team asks patient for name of their Usual GP. On loading record, check done on Usual GP field and updated if needed. If patient is part of the FA cohort, a pop up will be triggered letting Reception Team know the GP s recommendations for booking this patient. Reception Team following GP instructions and book appropriate appointment (urgent, routine or telephone triage) with Usual GP or member of Microteam at the next available appointment. If there is no appointments within the next 2 weeks patient advised to call back (provided with a day where their usual GPs appointments are released), or booked in with buddy if unable to wait. Urgent appointments are also booked in with usual GP, or buddy if they are not available. If neither is in surgery this will fall to whichever GP is available/any GP they have seen before.
