Frailty Care Planning Guidance for Ardens Users Templates to support care planning for frail patients Before you begin care planning with patients, you may find it easier to run your risk stratification first to identify patients who with mild, moderate or severe frailty. One tool you can use is the efi. This will allocate a score for your patients. You can then read code using the following: efi score Frailty level Read Code 0.13-0.24 Mild - People who are slowing up in older age and may need help with XabdY personal activities of daily living such as finances, shopping, transport. 0.25-0.35 Moderate - People who are slowing up in older age and may need help Xabdb with personal activities of daily living such as finances, shopping, transport. 0.36+ Severe - People who are often dependent for personal care and have a range of long-term conditions. Some of this group may be medically stable but others can be unstable and at risk of dying within 6-12 months. Xabdd Once you have coded the patient as frail, you can use the Frailty template to care plan with your patient. Don t forget you can bulk code your patients you do not have to code them individually. Please note: GMS Contract requirements for the identification and management of people with frailty - guidance on Batch-coding published NHS England is aware that some GP practices have batch-coded a Read code diagnosis of frailty based solely on electronic frailty index score (efi). Automated diagnostic coding without clinical judgement may lead to inappropriate diagnosis of frailty with consequences for patient care including inappropriate clinical interventions and future care planning based on a wrong diagnosis. Therefore, NHS England, the General Practices Committee of the British Medical Association and NHS Employers advise not using efi for batch-coding. Step 1 Undertake a review of the patient 1.1 Frailty Template: You will find this by clicking on Auto Consultation Ardens Care Plans Page 1 of 20 August 2017 v1
Then from the list that appears click on ardens Consultations D-L This will then give you another list and click on Frailty. The list is in alphabetical order to make it easier for you to find. You will now see this template: Ardens Care Plans Page 2 of 20 August 2017 v1
You will notice that some fields have a star next to them. These are National requirements. Recording information in these fields ensures you are capturing and coding the right information for your GMS contract requirements. If some values have been entered into the template previously these will show up on the right hand side when you click in the box. e.g. If you click in frailty status you will see that previously the status was recorded as mild frailty. You need to complete all (or as much as possible) of the template. You have now done the first part of the frailty review and care planning with the patient. You then need to review the long term conditions that the patient has in order to care plan appropriately. Click in the box LTC review this will take you to the template where you can review the patient s long term conditions Ardens Care Plans Page 3 of 20 August 2017 v1
Step 2 Review the long term conditions of the patient 2.1 LTC Review Template: You will now see this template: If you do not see this, click on the tab labelled review 1.2 Under take a review of each condition On the right-hand side of the template you will see this list: Click on Conditions and this will open up the review template for the first condition that your patient has. Ardens Care Plans Page 4 of 20 August 2017 v1
The first condition appears and you can click on start to complete the template. If you have completed this particular review recently, you can click skip to next to move onto the next condition. When you have clicked start a template like this will appear: Ardens Care Plans Page 5 of 20 August 2017 v1
You will notice that some fields have a star next to them. These are QoF fields. Recording information in these fields ensures you are capturing and coding the right information for your QoF points. You need to complete all (or as much as possible) of the template. At the bottom you will see a field called care plan: Click on the box New Diabetes Care Plan NB: For COPD this will be called New COPD Care Plan ; For Asthma it will say New Asthma care plan etc There may be some LTCs that don t have this field. The CCG is developing these. The care plan will open in a new word document. You will need to print this out and give it to the patient, as well as saving it into the patient s record. When you click on New Diabetes Care Plan the New letter form appears. Ardens Care Plans Page 6 of 20 August 2017 v1
Check the details are correct and click on Write Now. This will now open a word document: NB: These documents are not a complete care plan, although this is what Ardens has called them. These are supplements to support patients to self-manage their condition. These documents are part 1 of a comprehensive care plan. You will need to print this for the patient (Go to File-Print) and then save this to the patient record WARNING: When you save the document it automatically closes the window. You will have to reopen the plan in order to print it. If you are going to print the plan for the patient you need to do this first. Ardens Care Plans Page 7 of 20 August 2017 v1
You will then see this screen: Click OK. You have now finished your LTC review for the first condition. Once you have done the first LTC, the review template for second condition that the patient has appears: As with the previous review template, click on start or skip to next. Ardens Care Plans Page 8 of 20 August 2017 v1
Once you have done all the conditions you will be taken back to this screen: You have now done the second part of the frailty care planning with the patient. You should have printed and saved the supplement / self-management documents for each condition. If you have missed any, don t worry you can still access them from this template. Find the specific condition you have missed on the list here. Ardens Care Plans Page 9 of 20 August 2017 v1
Right click and a pop up appears. Click on Action This will open the template and for that particular condition and you can get to the care plan at the bottom of the template. You do not need to re-complete the template. Query? Do I have to do all the reviews at the same time? Answer: No. Under the conditions section, each LTC tells you when the patient last had a review for that particular condition. You may not wish to redo the review, but you will need to open the template to print and save the disease supplement for this condition. If you have all the reviews completed and supplements printed, you can move onto step 3 The Core Care Plan. Ardens Care Plans Page 10 of 20 August 2017 v1
Step 3 Create the core care plan Click on Future Care Planning You will then see this screen: NB: If you need to print any specific care plans, you can do this by clicking here. Click on Treatment Escalation Plan This is where you can discuss with the patient and record what they may like to happen if their condition gets worse. NB: Depending on the patient and their condition, you may feel that this particular appointment is not the best time to have the conversation. If this is the case, tell the patient that these fields will appear on their care plan, but they don t have to make any decisions now. These fields can be filled in at a later date. However, remember to explain to the patient the benefits of having this information recorded e.g. losing capacity in the future. Ardens Care Plans Page 11 of 20 August 2017 v1
On this page you also will see a field called Patient Goals. Clicking on this box will open a new template. This is where you can record any goals you agree with the patient to help them to manage their condition(s). These goals will auto-populate into the core care plan. You now need to create the core care plan and can do that on this page. Click on Print Generic Care Plan Ardens Care Plans Page 12 of 20 August 2017 v1
The New Letter form will open: Check the patient details and click on Write Now. This will now open a word document: You will need to print this for the patient (Go to File-Print) and then save this to the patient record WARNING: When you save the document it automatically closes the window. You will have to reopen the plan in order to print it. If you are going to print the plan for the patient you need to do this first. You have now done the third part of the Frailty review and care planning with the patient. Steps 1,2 and 3 combined provide the patients with a comprehensive care plan. You can now move onto step 4 medication review. Ardens Care Plans Page 13 of 20 August 2017 v1
Step 4 Medication Review As part of the care planning conversations and review of frail patients, a medication review should take place. On the LTC template is a button called Medication. Click on this to start the medication review The following template will appear: This template will help you to complete the medication review for the patient. If you wish to do a more detailed review, you can click on the Full Drug Review button and this will open up a more detailed template. The initial processes of care planning have now been completed. However depending on the severity of frailty, there are additional steps you need to take. Ardens Care Plans Page 14 of 20 August 2017 v1
Step 5 On-going Support. Mild Frailty Moderate Frailty Severe Frailty Give the patient a copy of their care plan Provide the patient with the Healthy Aging Leaflet and the Age UK Hertfordshire Leaflet Give the patient a copy of their care plan Provide the patient with the Healthy Aging Leaflet and the Age UK Hertfordshire Leaflet Give the patient a copy of their care plan Provide the patient with the Healthy Aging Leaflet and the Age UK Hertfordshire Leaflet Discuss with the patient ways in which they can improve their health as outlined in the leaflet. Consider signposting to HertsHelp and other voluntary organisations. Discuss with the patient ways in which they can improve their health as outlined in the leaflet Refer to community services for on-going care planning discussions Consider signposting to HertsHelp and other voluntary organisations. Refer to community services for on-going care planning discussions Consider signposting to HertsHelp and other voluntary organisations (e.g. hospices) to help with daily living activities. These patient should be discussed at MDT/GSF meetings Step 6 Sharing the care plan Care plan and care planning is most effective when others involved in the patients care can view them. You will need consent from the patient to share their care record. If the patient consents to sharing you will need to record this within their record and enable record sharing. Click on Future Care Planning Ardens Care Plans Page 15 of 20 August 2017 v1
You will then see this screen: Click on Sharing Records A new template will open: Click on SystmOne Sharing In/Out Ardens Care Plans Page 16 of 20 August 2017 v1
This template will appear and you can record the patient s preferences. The patient s record can now be viewed by other organisations and you can see information recorded on SystmOne by other providers. More information on record sharing and the My Care Record Project can be found on the CCG website. Step 7 Recording that a care plan has been provided You will need to re-open the frailty template. You can choose to do this step while you have the frailty template open in step 1, but you must provide the patient with a copy of their care plan. Frailty Template: You will find this by clicking on Auto Consultation Ardens Care Plans Page 17 of 20 August 2017 v1
Then from the list that appears click on ardens Consultations D-L This will then give you another list and click on Frailty. The list is in alphabetical order to make it easier for you to find. You will now see this template: Ardens Care Plans Page 18 of 20 August 2017 v1
At the bottom you will see a field called care plan: From the drop down box you can choose one of the following: Personal Care Plan Completed (XaRB2) Personal Care Plan declined (XaRB0) Personal Care Plan offered (XaRB3) Review of Personal Care Plan (XaRB1) This is where you can record if the patient has been given a care plan or if it was declined. You have now completed all the initial steps of care planning with the patient. On-going reviews of the care plan and updates ensures that the care planning process continues. Ardens Care Plans Page 19 of 20 August 2017 v1
Ardens / SystmOne Hints and Tips At the bottom of every template are the following buttons: Clicking on Ok will save the information you have entered into the clinical record and close the template. F12 function When you are in SystmOne, pressing F12 on your keyboard brings up a favourites menu. Here you can add templates / letters / forms that you regularly use so that they are easy to access. Find the item that you want from the list on the right-hand side and right click on it. A box will then open and you can click on Add to Favourites Once you have added it, it will appear on the left hand side. To remove it from your favourites, right click on the item on the left hand side. A box will appear with the option to Remove from Favourites. Click on this and it will be removed. Ardens Care Plans Page 20 of 20 August 2017 v1