TABLE OF CONTENTS


Introduction

This article focuses on the practical, end-to-end process for setting up, reviewing, and maintaining the Continuity of Care Status using the Ardens Resources.


For an overview of the resources, including background and clinical context, please refer to the Continuity of Care RAG - Overview support article.


Getting Started: Initial Setup 

Purpose

To set up the practice to use the Continuity of Care RAG model and ensure clinicians can begin recording the RAG status.


Step 1 - Activate Protocols

  • Click the EMIS ball > Configuration > Resource Publisher.
  • Navigate to Shared folders > Ardens Live National Content > Optional Protocols (inactive by default) > Continuity of Care (Foundry Model).
  • Right-click on each of the following protocols and select Status > Activate. 
  • RAG / Continuity of Care Alert – displays the patient’s latest RAG status in the pink alert box.
  • Continuity of Care: Patient Segmentation – prompts clinicians to update the RAG status when saving a consultation (optional).
  • The protocols will now be active.


Step 2 - Review Patients with no RAG Status Recorded 

  • Access Ardens Searches > 1.37 Administration - Risk Strat > Continuity of Care RAG > Registers.
  • Right-click the Registers folder, select Run, then click Yes to run all reports. 
  • Prioritise the Predicted reports. These identify patients who have not had a RAG status recorded within the last 12 months.
  • At this stage, you may want to prioritise which staff members will review the complex patients (red and amber status) and those in general good health (green status). Once decided, select the required report and click View Results.
  • To further filter patients by criteria, click Export > CSV and select Exclude report header, Replicate patient details for each item and Override hidden patients where possible. Click OK, then follow these instructions to filter. 
  • To record a RAG status for the patient once reviewed, access the patient record and double click on the Continuity of Care alert in the pink box, this should display as 'Continuity of care: UNKNOWN)'. 
  • In the Update RAG status section, select the appropriate status. 
  • Click Save Template.
  • The alert will update, and you can proceed to the next patient.


Ongoing RAG Status Reviews 

Purpose

To maintain the practice's Continuity of Care registers. A monthly review is recommended.


Step 1 - Register Maintenance 

  • Access Ardens Searches > 1.37 Administration - Risk Strat > Continuity of Care RAG > Registers.
  • Right-click the Registers folder, select Run, then click Yes to run all reports. 
  • Continue to action the Predicted reports and RAG Status: Unknown I Not recorded report.
  • Update patient RAG status as appropriate.


Step 2 - Data Quality

  • Access Ardens Searches > 1.37 Administration - Risk Strat > Continuity of Care RAG > Data Quality.
  • Right-click on the Data Quality folder, select Run, then click Yes to run all reports. 
  • For the top three reports (Record RAG Status as not previously recorded but predicted):
    • These patients have never had a RAG status recorded.
    • Review the record and update the RAG status (follow the same steps as Initial Setup – Step 2).
  • For the bottom three reports (Review RAG status as recorded XX but predicted):
    • Review each patient and decide whether the suggested RAG status should be recorded.

Step 3 - Review RAG Status

  • Access Ardens Searches > 1.37 Administration - Risk Strat > Continuity of Care RAG > Review.
  • Right-click on the Review folder, select Run, then click Yes to run all reports. 
  • Advise clinicians to complete a clinical review for these patients and update the RAG status accordingly.


Updating RAG Status 

Purpose

For clinicians to record the patient's current RAG status in line with best practice guidance.


Via a Consultation

  • Open the patient record and click Run Template.
  • Search for the Continuity of Care Ardens template.
  • Double-click to launch the template.
  • Review the current RAG status displayed.
  • In the Update RAG status section, select the appropriate status.
  • Complete the Care Team or Special Note / Key Message section if required.
  • Click Save Template.


Via a Protocol

  • Open the patient record.
  • The current RAG status is displayed in the pink alert box.
  • Double-click the alert to open the Continuity of Care Ardens template.
  • Update the RAG status if required and save.


Viewing RAG Status 

Purpose

To ensure all practice staff can easily view a patient’s current RAG status.


Pink Box Alert

  • Open the patient record.
  • The Continuity of Care alert in the pink box displays the patient’s current RAG status.


Additional Learning

To further your understanding of the risk stratification tools and how to make the most of Ardens resources:
 
If you require any further assistance on the process above, please contact Ardens support on: support@ardens.org.uk