Super NIS 2017-18

Holistic Management Part A

Depression Dementia
Smoking status Alcohol BP BMI Pulse rhythm Carer QRisk QDiabetes Bloods
screening screening
Bed/chair
All people Record
Smoking advice to See bound, As clinically
Audit-C aged 65 and As appropriate whether Calculate where appropriate
all smokers targets amputees appropriate
above carer or not
excluded
Management Part B
Mandatory criteria Discretionary criteria
All patients who are palliative, have dementia and or in nursing Enrol patients only at beginning of year. Chose and code individuals by
home. (Code very frail as palliative) May 2017.
Minimum number of patents equivalent to 12% of the 65 year old
population in April 2017 minus the mandatory patients
Join patients throughout the year
IC Complex
Not just 65 years. Include any patient aged 18+ years who is complex
Cohort
Codes for inclusion: 9NgzB (eligible for IC Complex pathway) AND 93C0 (consent to share record)
Functional Influenza,
Same day Anticipatory
Named Personalised screening Meds pneumococcal Last days of PAM
Consent tel access care plan as
clinician care planning (geriatric review zoster life patients questionnaire
to clinician appropriate vaccination
assessment)
Diabetes Hypertension CHD, TIA, PAD (No AF
CKD 3-5
Diabetes)
BP <140/80 BP <140/90
Additional reviews and
HbA1C < 59mmol/l < 65 years medication optimisation in BP <140/90 BP <130/80 BP <140/90
patients BP 140/90
Atorvastatin 20mg if QRisk
HbA1C < 75mmol/l 65 years
20%
Diabetes NO CVD: Atorvastatin Hypertension treatment for
20mg if QRisk 10% all patients <80 years with: Atorvastatin All patients >65 years, and
Atorvastatin 40mg or
Stage 1 hypertension AND 20mg if QRisk many at younger ages:
Diabetes PLUS CVD: Atorvastatin 80mg
CVD, CKD, diabetes, or QRisk 10% atorvastatin 40mg or 80mg
40mg or 80mg
20%
All patients with Stage 2
Urine ACR: ACE-I or ARB if
LTC Cohort hypertension
nephropathy or microalbuminuria Anticoagulation review
Foot check Patients <85 years and BP
>150/90 not on thiazide +
Retinal screening
ACE/ARB + CCB need review
Additional reviews and medication CHADSVASC score 1 and
Patients >85 years with
optimisation in patients BP on anticoagulant
systolic BP <120 need review
140/80 or HbA1C > 59 (<65y) or
to avoid hypotension
75 (65Y)
Hypo prevention: 65y on SU
Diagnosis with 24hr BP or
and/or insulin with latest eGFR
home monitoring
<60ml/min & HbA1C <53mmol/l
Annual person-centred review and care plan (holistic across all LTCs)
Annual pulse rhythm check ECG payment: 12 per ECG
Patients 65y Pulse rhythm check every 5 years
Diagnosis Annual review Follow-up post admission
COPD action plan
Spirometry/FEV1 to reassess severity COPD
MRC dyspnoea scale
Smoking cessation COPD unplanned admissions and A&E
All new cases of COPD diagnosed
COPD Review rationale for prescribing high intensity attendance require telephone follow-up
with spirometry
corticosteroid therapy within 1 week of receipt of hospital summary
Refer pulmonary rehab
Reduce inhaled corticosteroid use in patients with mild-
moderate COPD
20% reduction in payment if patients with COPD AND no asthma diagnosis AND FEV1 >50 AND less than 2 exacerbations in previous 12
months ARE prescribed an inhaled corticosteroid
Zoladex/Prostap injections: payment 43.50 per injection
Cancer Cancer register and cancer patient analysis tool audits Code treatments i.e. chemotherapy and
Exclude non-melanoma skin cancers Code cancers using 'B' Read code radiotherapy in EMIS
Antipsychotic Annual bloods: U&E, ALT, Depot injection: payment
SMI Physical health assessment Extended medication review
monitoring HbA1C, FBC, HDL 195 per year
Patient End ofcholesterol
life anticipatory Renal trigger Safe prescribing: Falls prevention >80y BP
Audits Care planning quality Dementia
experience care planning tool <120; hypoglycaemia prevention
Bi-monthly practice review of
MDTs Monthly CHS MDTs 10-12 EEHN MDTs Quarterly mental health MDTs
referral and diagnostic data