Download Quality Improvement Scheme (QIS) 2015/16 Frailty Register 28 out

Quality Improvement Scheme (QIS) 2015/16
Frailty Register
28 out of the 29 participating practices have added patients to their Frailty
register
The participating practices have assessed 21% of their over 75s for Frailty.
40% of those assessed had a degree of frailty. This has resulted in 1,584
patients being identified as frail (9.1% of over 75s in the participating
practices)
The development of Frailty registers will be continued across all practices
signed up to the 16/17 Quality Improvement Scheme, a Frailty audit is
currently being undertaken by the Commissioning Support Officers identifying
those patients on the frailty register who are not in the top 2% at risk group or
living in a care home. This group are then given to the GPs for consideration
to be referred into other services such as the Multi-Disciplinary Service.
How practices identified patients
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Screened patients 75+ on the unplanned admissions register when
attending for their 3 monthly reviews
Opportunistic screening during ‘flu season’ where increased numbers
of patients in this age category were likely to attend the practice.
Screened all housebound and care home patients for frailty
Depression
Practices undertaking this indicator were required to code adult patients that
present to the practice with new or a new recurrence of depression in
2015/16.
All 12 of the practices that signed up to this indicator have increased their
depression prevalence; the practices have identified 1116 patients with
depression. 44% of these patients were signposted to IAPT, with the
remainder receiving verbal advice and medication.
How practices identified patients
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GP’s, Practice Nurses and HCA opportunistically screened carers for
depression using PHQ9 audit tool
Ran searches to find patients taking anti-depression drugs who do not
have diagnosis of depression
Ensured all clinicians had copies of ‘We can talk’ credit card booklets
to hand out to patients for self-referrals
One practice integrated screening for depression at all Long Term
Condition review appointments
Quality Improvement Scheme (QIS) 2015/16
Hypertension
The aim of this indicator was for practices to find undiagnosed cases of
Hypertension and therefore increase their Hypertension prevalence
All seven practices that chose this indicator have shown an increase in
hypertension prevalence, Practices participating in the scheme have identified
634 patients with hypertension.
How practices identified patients
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Ran searches to identify patients taking anti-hypertensive drugs
without a diagnosis of Hypertension
Identified all patients with BP readings >140, with no hypertensive
diagnosis, offered ambulatory BP monitoring and lifestyle advice.
Utilised the ‘Values out of Range’ dashboard on RAIDR to help find
potential hypertensive patients
Coronary Heart Disease Prevalence
It was hoped this indicator would help identify patients with CHD and
therefore manage the symptoms associated with the disease and reduce the
chances of problems such as heart attacks and stroke
Three practices out of the four undertaking this indicator have increased their
CHD prevalence; Practices participating in the scheme have identified 58
patients with CHD.
How practices identified patients
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Ran drug searches, for example, in relation to prescribing for;
Nicorandil, OSMN, GTN spray. Patient records were then reviewed for
appropriate coding / treatment
Undertook validation on the existing register to ensure existing
prevalence accurately reported
Undertook CVD risk assessments and identify high risk patients for
further investigations/tests
Quality Improvement Scheme (QIS) 2015/16
Atrial Fibrillation
The aim of this indicator was to identify more AF patients to reduce patients at
risk of stroke, through improved identification, diagnosis and optimal therapy
Three of the seven practices that chose this indicator have shown an increase
in AF prevalence. One of the practices prevalence has remained the same
and three of the practices prevalence has decreased. Practices participating in
the scheme have identified 11 patients with AF
How practices identified patients
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Clinicians performed opportunistic pulse palpation of patients who
attended the practice for an appointment
One practice invested in a ‘MyDiagnostick device. MyDiagnostick is an
ECG recorder in the shape of a stick with metallic handles (electrodes)
at both ends.
All >65yrs patients had their pulses palpated when attending for their
chronic disease checks
Polypharmacy in the Elderly
This indicator aims to systematically address the issue of polypharmacy within
the elderly as one of the avoidable causes for hospital admission. The
scheme will potentially reduce the burden of inappropriate, unnecessary and
interacting drugs for patients.
All six practices signed up to this indicator identified patients aged 75 and
over who are on 4 or more oral medications. These patients will have their
medication reviewed and an anti-cholinergic score calculated. There have
been 910 face-to-face consultations undertaken by practices participating in
this indicator
How practices identified patients
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Identified the target population i.e. all registered patient aged 75 and
over who take 4 or more oral medications
Prioritised review around medication groups (e.g. Cardiovascular/
Diabetes/ Respiratory) and used RAIDR risk of re-admission tool
One practice designed an in house clinical template to support the
clinicians in accurately read coding when a face to face consultation
occurs and the outcome
Quality Improvement Scheme (QIS) 2015/16
Antibacterial Prescribing
Practices were asked to reduce their antibacterial prescribing (by assessing
each case for appropriateness to reduce the number of items issued).
12 of 13 practices who chose this indicator have shown a reduction in
antibacterial prescribing. The baseline average items/star PU for participating
practices was 1420 items/star PU. The average number of antibacterial items
prescribed for practices participating in the scheme (Birchtree excluded) as of
March 16 is 1221 items/star PU. This is a reduction of 199 items/star PU
compared to the baseline average.
How practices reduced their prescribing
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All GP’s had access to the up to date local antibiotic formulary, use of
which was reviewed at Practice Meetings
GPs undertook educational sessions in the practice around antibiotic
prescribing including e-learning tool
Use of the MicroGuide antibacterial guidance App highlighted to
clinicians
Audit prescribing by GP to try to identify patterns and variation in use
Opiate Prescribing
Morphine is the agreed first line agent choice for strong opioid prescribing
within primary and secondary care. Practices were asked to demonstrate a
commitment to reviewing the use of stronger opiates to ensure morphine is
utilised as first line of choice.
All nine practices undertaking this indicator have shown an increase in
prescribing morphine as first line of choice when prescribing opiates. The
baseline average percentage of the participating practices was 65.4%. The
average percentage for practices participating in this indicator now at 72%;
this is 6.5% increase from the baseline average
How practices achieved this indicator
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By not routinely offering transdermal patch formulations as first
line maintenance treatment to patients in whom oral opioids are
suitable
Reviewed use of Oxycodone and other identified non-morphine
potent opioids
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Education sessions for prescribing staff to ensure strong opiates
are started appropriate in the future, including raising awareness
of the WHO Analgesic ladder and refreshing knowledge of local
and national guidelines
Quality Improvement Scheme (QIS) 2015/16
Hypnotic Prescribing
Practices were asked to demonstrate a commitment to reducing total
Hypnotic prescribing.
11 of the 12 participating practices are showing a reduction in Hypnotic
prescribing. The average baseline ADQ/STAR PU for participating practices
was 1110 (excluding Victoria). The average ADQ/STAR PU for participating
practices is now 939. This is a reduction of 171 ADQ/STAR PU compared to
the baseline average
How practices reduced their prescribing
Offered and regularly re-enforced self-help advice and use of IAPT
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Identified a lead GP in the practice as the point of contact for patients
and staff
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Prescribed initial acute small quantities and did not issue further
prescriptions without consultation
Medicines Waste
Practices were asked to demonstrate a commitment to medicines waste
reduction by preventing the issuing of unnecessary or unwanted prescription
items. There was no baseline data for this indicator, so practices start at £0.
All seven practices that signed up to this indicator have demonstrated a
saving in medicine waste. The total savings across participating practices is
£53,320.
How practices achieved this indicator
Whole practice team checked with Pharmacies that all items are
required before processing the request via repeat medication schemes
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GPs have implemented opportunistic medicine reviews during
consultations
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Some practices gave out leaflets to patients and also displayed
information on our practice website
Quality Improvement Scheme (QIS) 2015/16
National GP Patient Survey
Practices were asked to improve the level of patient experience within the
‘Ease of getting through by telephone’ question of the GP patient survey.
Initial benchmarking was taken from the July- Sept 2014 survey (results were
published in January 2015). The positive responses of ‘very good’ and ‘good’
were combined to make an overall positive baseline figure.
Two of the three practices have seen an improvement on their patient’s
responses to this question. The average for all participating practices has not
changed from the baseline figure.
How practices achieved this indicator
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Advertised online services on prescriptions, posters in waiting room,
message on call display board and on patient leaflets on Reception
desk.
One practice implemented an extra telephone line which is staffed
between 8.30am and 9.00am
Hartlepool and Stockton-on-Tees CCG would like to thank you all for the hard
work practices have put into the Quality Improvement Scheme.