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Proactive care frameworks for long term conditions

Those with long term conditions, such as diabetes and asthma, are encouraged to actively manage their conditions.  In light of changes made to primary care services due to COVID-19, solutions are being developed and implemented to support people with long term conditions.

The West of England AHSN is working with primary care partners to implement a set of tools called Proactive Care Frameworks. The Frameworks were developed by UCLPartners to support identification, risk stratification and management of primary care patients post-COVID-19.

The frameworks aim to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, while reducing GP workload. This is an opportunity to consider redesigning delivery of care, providing those with long term conditions greater autonomy and support in self management.

Jump to download our free Implementation Resources.

What frameworks are available? What support do they offer?

The frameworks include atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma and COPD.

The frameworks are being implemented by GPs across the country, helping practices to identify who needs priority care, and those whose care can safely be delayed.

The frameworks are comprehensive and include:

  • Comprehensive search tools to risk stratify patients – built for EMIS and SystmOne.
  • Pathways that prioritise patients for follow up, support remote delivery of care, and identify what elements of long-term condition care can be delivered by staff such as Health Care Assistants and link workers.
  • Scripts and protocols to guide Health Care Assistants and others in their consultations.
  • Training for staff to deliver education, self-management support and brief interventions. Training includes health coaching and motivational interviewing.
  • Digital and other resources that support remote management and self-management.

All the frameworks are free and available to download from the UCLPartners website.

Getting started – download our free implementation resources

We have created a step-by-step implementation checklist that you can use to structure and lead activities with your practice team. The checklist helps you to set a project timeline and includes ‘how-to’ videos, worksheets and quality improvement approaches. We hope that by following the steps you will be able to plan and prepare for implementing the Proactive Care Frameworks.

Watch our short video where Kate Phillips, Senior Project Manager, gives a brief overview on using the implementation checklist:

Our approach

The West of England AHSN is supporting this project by initially working with a small number of surgeries to pilot the frameworks for asthma and type 2 diabetes. The implementation resources available for participating practices include access to motivational coaching, facilitation of team meetings to discuss project goals and workforce changes and signposting to clinical training and resources.

By sharing learning between these pilot sites and across the AHSN Network, we are able to understand the requirements and success criteria for implementing the frameworks more widely.

If you are interested in support from the West of England AHSN or would like to offer feedback on our implementation resources please contact:

What other resources are available?

Additional tools and approaches are available to support patients with long term conditions.

Primary Care

At the West of England AHSN we are working on a wide range of initiatives to support primary care.

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