Healthcare Improvement Scotland

Long-Term Condition Support in Primary Care: Exploratory Workshop (July 2020)

UCL Partners

Long-term condition support - a package of tools and resources designed to enable primary care teams to continue to effectively manage patients with a number of long-term conditions.

Matter of Focus

From fixer to facilitator: evaluation of the House of Care programme in Scotland (July 2020)

The House of Care Programme aims to transform primary care to focus on what matters to people. It is part of a family of approaches seeking to shift health and social care to more preventative, personal outcome focused, person centred and asset-based approaches.

The Scottish School of Primary Care’s Multi-morbidity Research Programme

“Multi-morbidity is now the norm rather than the exception in Scotland. It is socially patterned, being more common and occurring at a younger age as deprivation increases. Whole-system interventions are required to improve the care and outcomes of care for patients with muti-morbidity”

Please note: the data in these slides may no longer be accurate

Information to support the Respiratory community

The British Thoracic Society (BTS) has published information to support the respiratory community during the COVID-19 outbreak, including community respiratory services, COPD and COVID-19 for HCPs, advice for HCPs treating patients with asthma, and obstructive sleep apnoea.

The Primary Care Respiratory Society

The Primary Care Respiratory Society has drawn together a wide collection of resources of information which will be updated regularly.

COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease

The purpose of this guideline is to maximise the safety of patients with chronic obstructive pulmonary disease (COPD) during the COVID-19 pandemic, while protecting staff from infection. It will also enable services to make the best use of NHS resources.

4.2 When planning changes to usual care, take into account people's access to digital and online resources, digital literacy and any preference for verbal or written support (for example, digital-only services could lead to inequalities of access for people with limited internet access).

4.3 Think about how to modify usual care to reduce patient exposure to COVID-19 and make best use of resources (workforce, facilities, equipment), for example:

• switch respiratory services to telephone or virtual consultations, including routine annual reviews

• defer routine pulmonary function testing

• defer oxygen follow-up assessments if possible

Online pulmonary rehabilitation resources

This covers self-management, home exercise and educational materials.

Peak flows and microspirometry

Peak flow charting and microspirometry are undervalued in guidelines and were underused in primary care even before the COVID pandemic, but have enhanced importance now given the difficulties with access to more formal respiratory function testing.

Home Blood Pressure Monitoring – validated monitors

The BHS recommends that only properly validated BP monitors be used both in the clinic and at home. All the monitors listed on their website have been clinically validated. This means that all the machines, regardless of their cost, give reliable readings when used correctly. Please note that added cost does not equate to added accuracy.

Switching appropriate patients to DOACs

Switching appropriate patients from warfarin to a DOAC may be considered to avoid regular blood tests for INR monitoring. Whilst DOACs require blood tests to assess renal function throughout treatment– the monitoring is more predictable than INR testing with warfarin. Switching from warfarin to a DOAC must be done with careful consideration as not all patients are suitable for a switch to DOAC, and in some cases, specialist advice may be required.

COVID-19 rapid guideline: chronic kidney disease

The purpose of this guideline is to maximise the safety of adults with chronic kidney disease during the COVID-19 pandemic. It also aims to protect staff from infection and enable services to make the best use of NHS resources

3.8 For patients who are stable on treatment, assess whether it is safe to reduce the frequency of routine blood and urine tests during the COVID-19 pandemic. Take into account any comorbidities and whether their CKD is progressive. (NICE's guideline on chronic kidney disease provides recommendations on the frequency of routine monitoring.)

3.9 Encourage self-monitoring and self-management (including blood pressure monitoring) for patients who are able to do this. Give them access to their medical data (including diagnosis, comorbidities, test results, treatments and correspondence) through information systems such as PatientView or primary care electronic records systems.

3.10 Ensure that patients who are self-monitoring or self-managing know when they should seek help and who to contact.

The Patients Association

Questions to ask your GP

• Dealing with a long-term condition diagnosis can be overwhelming.

• Below are some questions to ask your GP which can help you get the information you need.

• They are just a guideline. If there is anything else you want to know, ask.

Diagnosis

• What are my test results?

• What do these results mean?

• What will happen next?

• What will I do?

• What will my doctor do?

• Where can I find out more about my condition?

• Who can I contact for more information?

Support

• How do I meet other people with the same condition?

• Is there a local support group or national charity that provides information and support?

Practical

• Is there equipment which could help me?

• How do I get that equipment?

Self-management

• Are there any self-management courses I can attend?

• Are there any lifestyle changes I should make?