Year of Care aims to support organisations and clinicians to implement high quality personalised care and support planning for people with single and multiple long-term conditions. It replaces the existing separate annual disease reviews.
For those practices incorporating the Year of Care process, Ardens has made available resources to assist with this.
To view a recording of the Year of Care webinar, click here.
Step 1 - Recall
The Ardens LTC recall system will support with recalling patients by birth month. For more information on how to use this please click here.
Step 1 - Information Gathering
To support the recording of the patients initial tests and checks, the Ardens Multi-Morbidity Initial Consultation template highlights the patients long-term conditions and will allow the HCA to capture the patients basic history, examination, and to carry out relevant blood tests.
The Ardens Blood Test Due Analyser will support users with identifying all the blood tests which are due now (or shortly) for the patient, ensuring the maximised use of that initial contact. The ’Blood test Due Analyser’ pops up in the bottom right hand corner of the screen, or can be accessed using the F12 key. We recommend doing this before launching the Multi-Morbidity Initial Consultation template.
The 'Multi-Morbidity Initial Consultation' template can be accessed via the Run Template option within a consultation. Search for the 'Multi-Morbidity Initial Consultation' template and complete the required information.
For further information on how to use the Multi-Morbidity templates, please see the following support article.
Step 3 - Preparation
The next stage of the Year of Care process is to produce the preparation planning document (agenda setting prompt and results) to be sent to the patient. To support practices with identifying patients to be sent the preparation planning documents, Ardens has created the following search and report:
To locate the search and report, navigate to the Population Reporting module > Ardens Searches >
1.11 LTC Reviews - Year of Care search folder.
Right click on the search folder and select Run to display the results. Once run, select the 1a. No preparation planning document sent since initial consultation search and view the list of patients by clicking on the Population Included tab.
Review each patient, checking the required results are available.
When it is time to send the patient the preparation document, within the patient record, click on the F12 key on your keyboard and launch the YoC Document Launcher protocol.
For further information on how to add to your F12 key, please see the following support article.
This will launch the 'Preparing for Care Planning' document and will merge through the patients recorded test results and information.
Once you have saved the document into the patient's record ('Save and close'), the document can be printed or emailed.
Note - when created and saved, this document adds a code to the patient's record 'Long term condition summary sent to patient'. This indicates that the document has been created but it is not possible to track whether or not it has been passed to the patient.
Emailing or printing the document
Navigate to the 'Documents' tab:
Then choose View/Print > View/Print items:
You will have a choice at the bottom of the screen to 'Print' or to 'Send'. If choosing to email, you can select 'Send' and then 'via Email', which will launch an email window with the document included as an attachment. You can then add your own message and address the email appropriately.
Do not forget, at this point, to book the patient's follow-up appointment following practice processes.
Step 4 - Conversation
During the patient's follow-up appointment, to support the clinician recording the outcome of the discussion, the Ardens Multi-Morbidity Annual Review template is available.
The template can be accessed via the Run Template option within a consultation. Search for the 'Multi-Morbidity Annual Review ' template and complete the required information.
For further information on how to use the Multi-Morbidity templates, please see the following support article.
The Care & Support Planning page will allow the clinician to code 'Care Plan given to patient'. If the clinician wishes to produce a further care plan, the preparation document can be relaunched via the F12 key and edited where required.
Additional Searches
The following searches are available to ensure patients are appropriately followed up:
The searches can be found in the Population Reporting module > Ardens Searches > 1.11 LTC Reviews - Year of Care search folder.
Search number 2 will identify patients who have had a preparation document sent more than 21 days ago but no annual review code has been recorded Review the list of patients and apply any missing annual review codes, ensure coding is correct or check an appointment for the patient has been booked.
Search number 3 will identify patients with a completed annual review but there is no care plan code added after this date. Review the list of patients and apply the relevant care plan code.
Search number 4 displays patients that have completed all stages of the Year of Care process.
The For info, Initial appointment > 14 days ago, no planning document sent since search will identify patients with no preparation document. Review the list of the patients and decide if a preparation document should be sent.
If you require any further assistance on the process above, please contact Ardens support on: [email protected]