Annual Long Term Condition Review

We have introduced a new Annual Long Term Condition Review for our patients that have one or more Long Term Conditions.

Our aims:

• Improve patient health and reduce impact of their long-term conditions as much as possible.
• To prevent patients having to visit the Surgery multiple times, especially if they have multiple conditions.
• Making our services more convenient for our patients.

How we will do this:

• Invite each patient for a birthday review.
• Book bloods (if needed) and appointments through dedicated phoneline – this should make the process of booking appointments easier.
• Face-to-face appointments with Healthcare Assistants and GPs (in escalated cases).
• Patients will be invited by various means, whether that be through letter, email or our text messaging service so please keep your preferred contact details up to date (see our website handles for this).

You may find that the period between your last review and your next review is more, or less, than 12 months as this will enable us at the Surgery to transition over to our Annual Birthday Medical Review for 2022/2023.

Whilst we do encourage patients to attend Annual Long Term Condition Review, if you can’t, or don’t want to attend your review, we would be grateful if you could notify the Surgery so that we do not send you anymore reminders until the following year.

What is a Long-Term Condition?

A long-term condition includes illnesses such as:

• Stroke
• Diabetes
• Dementia
• Heart Failure
• Asthma
• COPD
• Coronary Heart Disease (CHD)

These conditions require an annual review to ensure that the condition is being managed appropriately (by you the patient and also by us as your healthcare provider), identify any problems or concerns and ensure patients are confident to deal with their condition between review.

How does the process work?

Patients with one or more long term condition will be invited for their Annual Long term condition Review the month of their birthday. If this is the case, all relevant conditions will be reviewed within the one annual review process. This ensures that you are only attending the Surgery when you need to and that we are not asking you to attend the Surgery unnecessarily. You will receive a letter or SMS message which explains what to do next.

Some conditions may require an interim review e.g. at six months, and if so, this will be discussed at your Annual Long term Condition Review.

As this is a new process, we would appreciate any feedback on how the system works for you.

Do I need to bring anything with me? 

• As per the letter/email you receive, you will be required to have a urine test and blood test in advance.
• If you can check your blood pressure at home, it would be useful for readings to be monitored the week leading up to your appointment so the Healthcare Assistant can use your readings as part of your review: Home BP Template
• If you use an inhaler, please bring them and any associated devices with you.

How to book?

Patients will be contacted in the month prior to their birthday to get booked in for their Annual Long Term condition Review. This may involve coming to the Surgery beforehand to complete relevant blood tests and hand in urine tests to ensure results are back in time for your review with our Healthcare Assistants.

If you have not been contacted and feel as though you should have been, then please contact the Surgery on 01268 798581.

Timeline

1. Patients will be contacted during the month of their birthday via email, PATCHS, SMS or letter.
2. Patients will get booked in for an appointment with the appropriate length depending on chronic disease. At this point, patients will also get instructions for blood tests and urine tests.
3. Patient will be seen by HCA during their month of birth and have the relevant review.
4. If Nurse or GP involvement is not required, Patients will have a medication and follow-up review consultation with a Pharmacist. If Nurse or GP involvement is required, the HCA will discuss this with you at your appointment.
5. Once your medication and follow-up review with the Pharmacist has been completed, unless you require a 6 month check up (based on your chronic disease) you are not required back at the Surgery until the following year.