Care and Support Planning (Year of Care)
Our EMIS Web care and support planning solution closely follows the NHS Year of Care initiative and offers a framework to provide personalised care planning for people with long term conditions to improve their care. It has been produced in collaboration with Aylesbury Vale CCG. Since these long-term conditions are currently part of QOF we have built into our solution all of the QOF indicators for each long-term condition. These indicators remain relevant during this care and support planning process.
Our Care and Support Planning solution is included within QToolset Enterprise or can be purchased as a stand-alone package. Please contact us to discuss this.
There are 3 steps for patients to follow in this clinical pathway. It is designed to be used by different members of the practice team and enables HCAs, nurses, and GPs to be involved in the process and facilitates effective handover between staff and enables joined up care.
Our Care and Support Planning solution is included within QToolset Enterprise or can be purchased as a stand-alone package. Please contact us to discuss this.
There are 3 steps for patients to follow in this clinical pathway. It is designed to be used by different members of the practice team and enables HCAs, nurses, and GPs to be involved in the process and facilitates effective handover between staff and enables joined up care.
Step 1: The patient attends to see an HCA who will take a basic history, examination, and relevant blood tests using the data entry template. This template covers the long-term conditions listed below. It is a "smart" template and only displays the long-term conditions that the patient actually has.
Please note this screenshot includes all the long-term conditions available within our Care and Support Planning solution.
Please note this screenshot includes all the long-term conditions available within our Care and Support Planning solution.
Step 2: The patient receives their blood and examination results in the post so they can consider what they would like to discuss at their follow-up appointment. These documents are all produced automatically by an administrator who presses a single button in EMIS Web.
Please note the following screenshots are examples and do not include the entire document that the patient receives.
Please note the following screenshots are examples and do not include the entire document that the patient receives.
Step 3: The patient books a follow-up appointment with their GP to discuss these results and make a plan for the coming year. During this consultation the GP will use the Follow-up template that displays all the results from the previous consultation and allows recording of data in areas where the HCA was not qualified to do so.
At the end of the consultation they will complete a "Goals and Action Plan" document that summarises the discussion and gives the patient a plan to work towards over the following 12 months.
At the end of the consultation they will complete a "Goals and Action Plan" document that summarises the discussion and gives the patient a plan to work towards over the following 12 months.