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Innovation in Long-Term Condition Management: the UCLPartners Proactive Care Frameworks

Best Practice Bulletin: Edition 10

01 Sep 2021

Innovation in Long-Term Condition Management: the UCLPartners Proactive Care Frameworks

Innovation in Long-Term Condition Management: the UCLPartners Proactive Care Frameworks

A major new innovation for long-term condition management is now being adopted by primary care networks in a new national programme called NHS Proactive care @Home. The UCLPartners Proactive Care Frameworks have been built by primary care clinicians to support the delivery of routine care for people with long-term conditions in the new world of primary care post COVID.

Covid has disrupted a lot of routine clinical management. As we continue to deliver the vaccination programme and manage the latest surge in cases, we are also worried about our patients with conditions such as CVD, diabetes, hypertension and COPD. These are patients who rely on regular proactive care to keep them well and to prevent relapse and complications. As we emerge from the pandemic, we face a backlog of patients whose reviews may have been delayed and whose condition may have deteriorated, and we have the added challenge of trying to deliver as much care remotely as possible.

The UCLPartners Proactive Care Frameworks cover 6 conditions: hypertension, atrial fibrillation, high cholesterol, Type 2 diabetes, COPD and asthma. Each framework includes comprehensive search and stratification tools built for EMIS and SystmOne. These help us prioritise patients, identifying those who are poorly controlled or at high risk (and need an early appointment for clinical review), and those who are stable and may not need a review for several months. This helps us to manage our team’s workload and to meet QOF and other targets for treatment optimisation.

In addition, the frameworks include pathways that deploy the wider primary care workforce (additional roles such as health care assistants, wellbeing coaches, social prescribers) to support patient education, self-management and behaviour change in a systematic structured way. This helps to deliver more personalised care for our patients and saves time for clinicians who can focus on clinical management.

In each framework we have collated a broad range of digital and other resources for clinicians, wider staff and patients to underpin remote care and self-care. These resources include education links to help patients understand their conditions, videos teaching patients how for example to take their blood pressure remotely, use their inhaler or check their feet for diabetic complications. And they include brief interventions and signposting links that staff can use for smoking cessation and physical activity etc. There are also scripts and protocols for wider staff roles to guide them in their consultations, and these take a multimorbidity approach – as many of our patients have more than one conditions.

UCLPartners and other Academic Health Science Networks around the country are working with local Integrated Care Systems, clinical leads and training hubs to support PCNs who are adopting the frameworks, helping them with project management and workforce development and training, and local adaptation of the pathways.

All of the resources in the UCLPartners Proactive Care Frameworks are free and available on our website:

Dr Matt Kearney, GP and Programme Director UCLPartners AHSN

Dr. Matt Kearney, Programme Director, UCL Partners

View all Best Practice Bulletin: Edition 10