Managing your Workforce for Proactive Recall using Risk Stratification
Recall has suddenly got really difficult post COVID as we need to think more intelligently around how to manage our patients with their long term conditions in a constantly evolving workforce, myriad of co-morbidities and newer virtual ways of communicating with them. This blog looks into this problem in more detail with proposed solutions to this complex conundrum.
Does QOF actually work?
I'm sure many of us sitting in clinics performing our proactive care on our patients wonder if calling patients who are on the whole stable yearly actually makes any difference to their disease progression and mortality.
Interestingly the British Journal of GP released an article albeit in 2017 looking at the impact of QOF. I don't think we've any systematic reviews since but the findings were very interesting. QOF started in 2004 so there has been enough time to possibly see its impact.
The QOF was associated with a modest slowing of both the increase in emergency admissions and the increase in consultations in severe mental illness (SMI), and modest improvements in diabetes care. The nature of the evidence means that the authors cannot be sure that any of these associations are causal. No clear effect on mortality was found. The authors found no evidence that QOF influences integration or coordination of care, holistic care, self-care, or patient experience.
Firstly I think it's impossibly difficult to be able to work out as confounding variables are a plenty and it’s difficult to see which affects outcomes.
QOF has changed in terms of its targets which I believe is trying to re focus our energies to create more tangible outcomes.
The New World
QOF from a recall point of view is complex. You have lots of targets with lots of conditions all changing at different times for you to manage so that come year end all patients have their qof targets ticked. Some targets are also time limited in year (eg Depression and Cancer Review)
In the brave new world we are in we are constantly trying to find better ways to manage our recall. In the surgery, we have 2 types of demands
Reactive Demand from patients calling for an appointment
Proactive Demand from Recall via QOF, LESs and DESs
We were fortunate enough last year to be able to focus more on passive demand just due to the pressure from Covid but this year it's all guns blazing.
Ironically March was also found to be the busiest year in GP since records began based more on passive demand so the pressure is mounting more from these both types of demand GPs consulted a record-breaking number of patients last month - Pulse Today
The other big problem we face is that we can no longer opportunistically "quickly do the blood pressure" as they leave the surgery as we are seeing much less face to face. So we need to find more intelligent ways to manage the recall which are different to how we managed recall before.
Tick Box Exercise
Don't you sometimes get that feeling that we are doing QOF just to tick that box? I know I do. There are a few targets which have outcome measures which we have to manage (eg blood pressure control or Hba1C control). In total there are about 78/635 points linked to outcomes = 12% which is generous when you consider thresholds too. The remaining 88% is attributed to reviews and measuring values which are more qualitative or have no bearing to getting patients better. For example we record the MRC scale on COPD as a non outcome driven target. If we were make this target outcome driven it would change for example to percentage of COPD who improved their MRC scale by 1 in the last year.
I'm not saying at all that everything should be measurable as there is a lot of qualitive work we do with our patients which is so important.
Another aspect to consider is I also do think we are giving similar focus to our stable patients who just need a gentle touch compared to our patients who are unstable and not controlled who need more frequent reviews to help them and their deeper dive into the sea of their morbidity.
The lack of focus on outcomes and unstable patients I believe are some reasons why we are not seeing as much of the expected outcomes we should by now with the investment in QOF over the years.
Risk Stratification
What if there was an evidence-based way of being able to subdivide our QOF patients into priority groups to give us the opportunity to focus more on those patients who need more time rather than treating all patients equal?
I came across the free UCL risk stratification tools (Search and risk stratification tools | UCLPartners) a few months back and was so excited by what they have to offer. This is an evidence-based set of searches to sub divide your population into priority groups and we now have a set of EMIS searches for us to be able to give focus where focus is due.
By spending more time on our more unstable patients there will be several benefits
our passive demand will decrease as these patients will not get as unwell
our mortality in our surgeries will go down
we will have less hospital admissions
we will achieve our quantitative QOF points quicker
We've been working with PatientChase to incorporate this to make it easier to identify and call in the right patients at the right time. With PatientChase we are able to offer risk stratification at a co-morbid level so you no longer just treat risk stratification at a conditions level.
With PatientChase we are now able to offer risk stratification at a patient co-morbidity level
The Big Black Box
BUT (and there is a big but) what are we looking at now? How many rabbit holes are we going down? With risk stratification we potentially have the following layers to manage
The new world of Recall
In other words it also gets more complex with a myriad of various processes which now also include a new workforce and the best contact media (Email, Telephone, Video, Face to Face). With all things considered we now need something like a Black Box akin to this diagram
For example Mr West who is a low risk Hypertensive patient needs a Health Care assistant for contact via email initially
In our new world of a varied workforce with different skillsets we need ways to generate demand to allocate patients to appropriate clinicians in a safe and efficient way. So there is a need to link patients in the correct pot by using middleware applications to manage this shift and divide the population accordingly to help the workflow.
Media
We now looking to contact patients in more ways than just face to face. These can be via
Email
Telephone
Face to Face
Media to contact them for their review
It's important to differentiate out how we can use different forms of communication and need to define differences between media used to contact them for their review and media used for the review. They can be the same or different. For example we can email the patient to let them know the they are due a review then in the email ask them to contact the surgery for a face to face.
In our surgery we are looking to focus on the mantra of virtual by default by contacting them in the cheapest method possible which is email or text. Post is too expensive and I'd urge you seriously to consider other methods of calling the patient in
Email to me is amazing as it's the best of both worlds in that if offers a rich environment to contact the patient with (like a letter) but for free so I'd very much recommend you look into this. In terms of governance issued please refer to my previous blog Email Consultations – Raza's Site (wordpress.com)
Email to me is amazing as it's the best of both worlds
Media used for the review
What type of media do you use for what type of target? We've been experimenting in our surgery around this and as with most non committal and vague answers, it depends. We've found the main hurdles are managing observations which need physical contact. These include
Blood Pressures
Peak Flows
Foot checks for Diabetics
Spirometry
In the review focus on managing their condion/s in the following order
Email -> Telephone -> Face to Face
But the main hurdle of going virtual surprisingly isn't the physical aspect, it's the patient and there has to be a will to try to go virtual on their side or it just doesn’t work. Off all the above aspects only really foot checks and spirometry need a face to face and patients can be worked up prior to face to face for these observations to make the consultation quicker and easier.
But the main hurdle to using virtual methods isn't the physical aspect, it's the patient.
We've found that email consultations especially for Asthma and Blood Pressure when the patient is motivated and happy to buy a machine or use the prescribed peak flow to monitor their levels are the most rewarding and enriching reviews because they have time to query about their condition and the clinician has time to reply. You can both use google to your advantage.
PCNs and ARRS Workforce for Recall. The right patient with the right staff
The plot thickens more as not only do you have to work out the best media to contact (Email, Telephone, Video, Face to Face) with the new workforce coming to you via the ARRS funding you also need to work out which type of patient is best suited to which role you have in the workforce. With the ARRS workforce we now have a varied skillset of clinicians from nurses to pharmacists to dieticians to HCAs on top of doctors all of which can manage certain type of intensity of patients.
We need a system which can work out of your recall population which ones need to go to your varied workforce based on their skillset and what they can manage.
This is why Risk Stratification is a game changer as it's the perfect key to fit the ARRS Workforce lock. We can push high risk to more experienced staff and tier down accordingly. This way we can optimise the way we run our recall by tying up the appropriate clinician to the right type of patient.
Risk Stratification is a game changer as it's the perfect key to fit the ARRS Workforce lock.
Non-QOF Targets
On top of QoF there are a myriad of target driven payments ranging from Nationally funded DESs down to Locally provisioned LESs which all require recall within the practice. CQC have also asked surgeries to look at the safety aspect of their practice care eg with DOAC monitoring and Drug Safety monitoring so it's no longer all about QOF but everything related to recall with the same principal that the patient is in the middle and has all their Qof and Non-Qof Targets associated with them. PatientChase has for sometime offered Non-Qof Targets via external searches from EMIS for users to focus on all target driven schemes.
Using Recall with PatientChase
The concept of recall is simple
you have the whole population you have to see in the year ie the demand.
you have the capacity in your staff to see them
Just like a toothpaste coming out of a tube you have to squeeze the patients at a certain rate otherwise the demand will be unmanageable.
PatientChase used at it's fullest is a full recall application which merges procured and managed targets and allows the user to contact them in which method they wish and records this back into EMIS. It automates the recall process in the surgery for both QoF and non-Qof treating both types of targets the same.
And now we are able to correlate patient complexity with workforce experience in general practice with Risk Stratification so high risk patients go to more experienced clinicians tiering down accordingly
Risk Stratification with PatientChase
With the latest version of PatientChase you can import the UCL searches which allow you to risk stratify any search which has any risk stratification searches in them.
This will help you be able to filter populations with multiple comorbidities into groups based on priority. The idea is.
The low priority groups
need low intensity care with a telephone or email nod of the head and a check of compliance
Can be managed by workforce other than doctors or specialist nurses
The high priority groups
need more focused and regular follow ups and more intense care possibly via face to face or regular updates.
Need more experienced workforce to manage them
PatientChase Screenshot with Risk Stratification (Dummy Patients)
Workflow for managing Recall using PatientChase
With all the above said how can we then actually operationalise our recall in a better way? Below is a proposed suggested workflow. Where PatientChase excels is in creating this workflow at a patient level including all the co-morbidities associated with that patient and all non-Qof related items so the focus is the patient and not the targets.
Step 1 Which type of Surgery Are you?
There are 2 types of entry points which are Month of Birth or Risk Stratification
Month of Birth
You are cutting up that recall toothpaste into months of birth to call in to manage the capacity in your system. This is a tried and tested patient centric model which works well as the capacity is static and patient know when their review is.
Risk Stratification
In theory recall should be all year long with each month being the same as the other but in reality we start the push after April and then rush to get everyone seen by March the following year. In this model the idea is to manage as many of the high risk earlier in the year which will have 2 effects
It will help you have more chance of bringing in patients abnormal values earlier to give you a better chance of achieving them come year end
You are focusing on the most important patients first which goes in line with trying to getting away from Qof being a tick box exercise as described above and also have the opportunity to call high risk patients in more often. We should be trying to divert our energies more on the high risk than low risk. At the moment we are giving each cohort the same air time.
However to do this properly it's important to do an exercise in asking patients to get their blood tests done early and prior to the risk stratification. This way you are more likely to focus on the right cohort with the most up to date information and has the added benefit of prepping the patient prior to their appointment helping the nature of the review.
We should be trying to divert our energies more on the high risk rather than the low risk.
Step 2 Risk Stratify and Manage the volume
Volume created from Month of Birth manages itself.
If going down the Risk Stratification arm the recall team has to decide how much of the flood gates need to be opened for what type of workforce so this requires some forward thinking. The idea is simply to keep the clinics full for the next week.
Step 3 Contacting the Patient
Once you have your population you can the siphon off the associated population with the associated workforce via correspondence informing them of how to book their appointment.
Already stated above there are several ways to contact the patient and really think about using SMS and Emails to save you money on the not insignificant stamp costs. Surgeries frequently say they don't have enough emails. We sent a blanket SMS message to our patients asking them to email us their email which we collected and entered in. Within a day we had 1,000 more emails of our list size of 4,000 so updating your email list is a tedious but I think an essential exercise if you plan to use this line of communication moving forward. As stated in my blog about email consultations, the IG is much more flexible to what it was previously on this front.
Step 4 - Virtual by Default
The focus should be virtual by default with email->telephone->F2F.
Even though for example diabetics need their feet checked and possibly weight done if they can't report back their weight to you, you can work them up prior to the F2F such that this consultation which will be a fraction of the normal time taken.
As stated earlier in the blog this should be a personal decision between the patient and the clinician. In our surgery patients love email only as well as face to face only. By having this flexibility the workload will get better as the patient who now does email was one who had to have a face to face and emails done correctly are an efficient and potentially more productive way of managing the patient's own condition.
Summary
Whether you use PatientChase or not I truly believe the future of how we should manage our disease registers should be skewed to spend more time on the higher priority patients. Tools such as the UCL Partners Risk Stratification Tool finally are here to help us achieve this.