The following support article will outline the additional searches available for the LTC recall system, to support practices with the recalling of vulnerable patients, planning ahead and identifying data quality issues.
The folders can be located within the Population Reporting module > Ardens Searches > 1.10 LTC Reviews - LTC Recalls > 2. Detailed Review searches.
Further details of how to use the Ardens LTC Recall System can be found here.
2. Detailed Review Searches
2.00 Recalls - Only Excluded Conditions
This search folder will include patient with CKD, Epilepsy and RA. All of these conditions only require the register to be maintained, however practices may still wish to recall these patients for a general review.
Each sub-folder is broken down by 1st and 2nd invitations due and patients are invited by month of birth.
An additional search folder is available to identify patients that may have two or more of these excluded conditions. These patients will therefore not be included in the specific excluded condition folder as they are only looking for that particular condition. Please note - this will be a very small group of patients.
2.01 Had Initial Review/Tests + need Annual Review
This search folder is useful for practices using the Ardens Multi-Morbidity templates. It contains the list of patients who have had their initial review with the HCA (Offer of care plan accepted code recorded in the template).
The list can be used for either inviting patients back in to see a Nurse/GP, or just for a clinician to review the notes and recent readings. It maybe the case that can consider the patient reviewed without getting the patient back into the building (either by telephone or just a notes review).
The searches are broken down by those patients seen within 3 days and 3 months and those patients seen more than 3 months ago:
Each sub folders contain a folder broken down by condition and then divided into those with a single condition and those with 2 of more conditions.
2.02 Interim Review (CKD & DM)
This folder contains searches which allows practices to identify those CKD patients and diabetic patients who may require an interim review.
As per NICE guidance, the CKD searches will only identify patients with a categorized CKD diagnosis e.g. G3aA3-G4A2,, G4A3 etc. We have therefore provided a Data Quality folder to pick up patients without categorization whose diagnosis you may wish to review. The Conditions - CKD Case Finders searches will assist with this categorization.
2.04 Review coding
This folder contains searches for QOF conditions that need a BP or Cholesterol recorded in the financial year, and searches identifying missing cardiovascular annual review coding.
We recommend running and actioning this folder before running your monthly invitation searches, to ensure all coding is accurate and prevent inviting patients unnecessarily for a review.
Some practices may not code a specific annual review for the patients on the CHD, Hypertension and Stroke registers, but instead use the fact of a Blood Pressure being recorded in the financial year as a ‘marker’ of the patient having been reviewed. The CHD/HYP/STIA with BP taken this QOF Year search folder will highlight patients with these conditions who have had a BP recorded for this financial year.
The CHD/PAD/STIA Cholesterol folder contains a search to identify patients with these QOF conditions who have had their annual review coded this fiscal year, but have not had a cholesterol recorded. There is also a search to highlight those who have an exception code for the QOF condition recorded but not an exception code for the cholesterol indicator, and have not had a cholesterol this fiscal year.
The Diabetes/Cardiovascular folder will identify patients who have been coded as having their Diabetes annual review, however their other cardiovascular conditions have not been coded as complete. You may wish to review their records and code any relevant cardiovascular annual review codes if appropriate.
2.05 Values above QOF threshold
This folder contains searches that allow you to see patients who have a condition for which their BP or Cholesterol needs to be in a certain range for QOF, however the latest recording this financial year is out of range.
It is a practice decision on whether they still wish to call patients in for a further review or apply the review code.
2.06 Exclude AF from recall
Some practices do not routinely recall patients for AF reviews. For practices that wish to exclude these patients from the system, the "Recall Excluder - AF' protocol can be batch applied to all patients coded with AF. For further details on how to do this, please see the following training video.
Please note - the patient will still return in the main recall searches if they have other conditions.
2.07 Q4 Birthdays - Best Practice
This search folder is there to help practices to pick up patients who have a birthday in the last quarter of the financial year, it maybe the patient does not come in for their review until April, or the first quarter of the new QOF year. As they have then had a review in the ‘current QOF year’ they then would not be picked up for a recall when their birth month comes around. This means they could go 23 months without a review.
To prevent this, these searches pick up patients with a birth month on Q4 of the year who have had a review in Q1 of the current year. Along with patients with a birth month on Q4 who have had a review in Q2. Practices can then review the patients to decide when / whether to recall them again.
2.08 Overview
This search folder contains searches to allow you to see the whole years’ work at a glance. This may help you to plan when you run each month, or when you need more staff! It also helps with catch-up during the year, and will pick up those patients newly registered that may have missed their birth month. The sub folder contains the same searches but for your Housebound/EoL/Care Home patients.
When running these group searches, set the date parameter to the beginning of the
financial year with no end date (see screenshot below):
2.09 Recall Arranged
There maybe times where the practice may want to recall a patient on a month that is not their birth month, this is where applying the recall arranged code helps. This folder contains a search to identify patients with a recall arranged code added to their record. Practices may wish to review these patients and decide whether or not the patient is still to be called in on the recall arranged month.
Once the search folder has been run, select the report and click on View Results. This will show you the patients month of birth and when the recall arranged code has been applied for:
For the example above, the following patient is born in January but will be invited in during December.
If you wish to revert back to calling the patient in during their birth month, edit the recall arranged date to align with the patients birth month.
2.10 LTC Mop-Up (for year-end use)
This folder identifies all patients (irrelevant of birth month) who still have reviews outstanding for this fiscal year, broken down by those that need first or second invite and those that have already had two or more invitations. These searches are particularly useful in the final quarter of the fiscal year. Right click on the appropriate folder, select Advanced options and enter a Relative run date of 31-Mar-2023.
As with the original month of birth searches, the results are broken down by contact method. Once you have invited your patients, the Code 1st Invitations folder will provide the details for batch adding the appropriate code.
4. Had 2nd recall >1m ago but no annual review
The QOF guidance states that a patient must have a minimum of two invitations within the proceeding 12 months recorded in their record, if the patient does not respond to the invitations, they will be automatically excepted from the indicator at the end of the financial year.
There maybe some practices that wish to still follow up these patients during the year. This search folder will break down by condition, those patients that have had two invitations sent more 1 month ago, but there is no indication of a review.
5. Data Quality: Check for review done + not coded
The following reports highlights those patients who may have had an annual review but are missing an 'annual review' code in their record. We recommend practices review these list of patients and add any missing elements of the review or a suitable exception code. You may wish to action this folder monthly before running your invite searches to ensure patients are not being invited unnecessarily.
Once the reports have been run, select the report and click on the View Results option on the EMIS ribbon to view the list of patients.
If you require any further assistance on the process above, please contact Ardens support on: support-emis@ardens.org.uk