Presentation by Dr Lauren Moorcroft, GP Partner - Brookvale Practice at the Supporting recovery in Primary Care using Proactive Frameworks for Long Term Conditions event on Thursday 15 September 2022.

1. Proactive team approach to
Multimorbidity
September 2022
Dr L Moorcroft, GP partner

2. • What we did
• Patient outcomes and our experience
• Our next steps
Our experience of remote reviews, digital first
triage and risk stratification approaches for
chronic disease reviews in Runcorn

3.  Remote digital asthma reviews for low-risk patients using Accurx Floreys, an Accurx
in-house template and UCL risk stratification searches (Proactive care frameworks -
UCLPartners)
 Trial of mHealth to support all but especially promoted with low-risk asthmatics and
diabetics as stratified using UCL searches
 Lipid optimisation using UCL risk stratification searches to target highest risk and
with medicines management pharmacists contacting these patients for a proactive
review
 Making every contact count work at vaccine clinics and with a reception screening
template to capture BP, weight, alcohol, smoking and chronic disease monitoring for
those attending/booking for their COVID and Flu vaccines
 AFQI and BPQI tools to risk stratify highest CVS risk patients and target loans of BP
meters and to filter complex multimorbid patients to our “One stop” clinic
(Brookvale approach)
What we did

4. Accurx Asthma Plan
and Video template

7. LD, CKD, Dem,
CHD, HF, Stroke,
COPD, BAME

8.  3291 patients weighed in practice between Jan-Nov 2021 - 593 in vaccine clinics. Of
sample of 200 42% had gained 4kg or more in pandemic (2019-2021)
 Case finding 66 new hypertensives, 52 new diabetics by proactive work
 Number of asthma reviews maintained at pre-pandemic rate due to remote working and
risk stratification approach (372 reviews done 2018-2019, 391 2019-2020, 389 2020-
2021)
 Even when adjusted to consider low risk patients only, patients had fewer exacerbations
and urgent care contacts via remote or face to face review than telephone review, we
have a hypothesis from patient interviews that this is from having their asthma plan and
video link sent via Accurx in-house template to their phone to refer to.
Patient outcomes

9. Patient outcomes

10.  Patient uptake was poor with mHealth - COPD 2, Asthma 9, Diabetes 6, Heart 2 (eldest
69y) and numbers using the app also poor - Asthma (3), Diabetes (3), Heart (1)
 BP@home - good uptake (158 since June 2021) and returning (only 1 with failure to
return). Same for Oximetry@home; loaning out to 216 since Dec 24th 2020 with attrition
of only 4 oximeters despite staff initial concerns we would not see this equipment
returned to practice. A disclaimer and admin & clinical lead was key.
 Staff experience was finding of some replication of work / difficulty aligning with recalls
process for QOF – one patient had 4 attendances in one QOF period as UCL searches are
not aligned with QOF recalls due.
 AFQI now a lot of replication with the IIF CVD-05 indicator and PCN pharmacist work for
Edoxaban switches for the protect aim (treat with anticoagulation)
Our experience

11.  COPD – very few are low risk in our population (<10 each search run out of 300+
register). We can’t reduce workload by risk stratification here as only a few have
qualified for a low-risk remote review. Dedicated respiratory lead nurse and respiratory
clinics for our high-risk patients had supported here but we are proud of her as she is
leaving to take up a nurse manager role
 IIF Respiratory indicator FeNo 60% target curve ball for remote reviews
 Note 283 total smokers on a 651 register = 43% for asthma. Our team thinks this makes
most of our register higher risk than appear and we should have lower threshold for
telephone/face to face review with HCP to support here
Our experience

12.  Patient feedback measured by survey for experience/acceptance of
digital/video/telephone/face to face/group/one stop chronic disease reviews
 Pharmacy-led remote low risk reviews now we have recruited our own practice
pharmacist (lipids project experience showed this was well accepted by our patients)
and would work really well we think for other clinical areas such as asthma and
hypertension
 Clinician-led high risk recalls parallel to QOF recall process
 Peak flow meters – develop a lending protocol along with BP meters and Sats probes
since we find the expense of the meter when prescribed limits patient engagement,
remote reviews and proactive self-care for our patients
 Promote screening template for afternoons/proactive phone calls e.g. for QOF recalls,
new staff training
 Align with CORE20Plus5 objectives; use more low-risk remote reviews to free up more
outreach/proactive work for Plus groups, severe mental illness patients and proactive
case-finding for cardiovascular disease
Next steps

13.  Most important is worst patient outcomes are for those with no reviews – unclear if
digital reviews help or hinder this group to engage.
 Align with CORE20Plus5 objectives; use more low-risk remote reviews to free up more
outreach/proactive work for Plus groups, severe mental illness patients and proactive
case-finding for cardiovascular disease
 One stop growing as our numbers of complex multimorbid patients grow - two one stop
clinics/week - growing team around this (ANP, GP registrars, PCN Mental health worker,
Pharmacist)
Next steps

14. Proactive team approach to
Multimorbidity
September 2022
Dr L Moorcroft, GP partner