The QOF 200607 Strategies for gaining full points

1
The QOF 2006/07Strategies for gaining full points

• Kathie Applebee

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2006/07 1,000 QOF points

• Clinical 655
• Holistic care 20
• Organisational 181
• Additional services 36
• Patient experience 108

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Full/high QOF points

• Identify the patients
• Do the work
• Record the data
• Run recall systems
• Log and chase DNAs
• Exception report
• Constantly monitor progress

4
Full/high QOF points

• Identify the patients
• Do the work
• Record the data
• Run recall systems
• Log and chase DNAs
• Exception report
• Constantly monitor progress

5
Identify the patients

• The values of the clinical domain points depend
  on the size of your practice and the numbers of
  patients in each disease area (except palliative
  care)
• Improve your prevalence to improve patient care
  and increase the value of your points

6
Potential patients for registers

• On repeat medication, without prescribing
  indications
• With disease entries but wrong codes used not
  picked up by IT system/QMAS
• With high BP, cholesterol etc. records but
  lacking diagnosis and/or treatment
• Lacking investigative procedures eg no BP

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Examples of codes to check

• Coronary heart disease 14AA. H/O heart disease
  NOS
• Heart failure 1O1..00 Heart failure confirmed
• Stroke and TIA 14A7. H/O CVA/stroke
• Hypertension 14A2. H/O hypertension
• Hypothyroidism 1432 H/O hypothyroid disorder
• Diabetes 1434.00 H/O diabetes mellitus
• Mental health 146.. H/O psychiatric disorder
• COPD 66YL.11 COPD follow-up
• Asthma 14B4.00 H/O asthma
• Epilepsy 1473.00 H/O epilepsy
• Cancer 142..00 H/O malignant neoplasm
• Dementia 1461. H/O dementia
• Chronic kidney disease 1Z1..00 Chronic renal
  impairment
• Atrial fibrillation 14AN. H/O atrial
  fibrillation
• Learning disabilities ZV40000 Problems with
  learning

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Full/high QOF points

• Identify the patients
• Do the work
• Record the data
• Run recall systems
• Log and chase DNAs
• Exception report
• Constantly monitor progress

9
Do the work

• Why do some patients miss out?
• Dont attend
• Dont help themselves eg attending when asked
• Arent pushy dont like to bother the doctor
• See stressed / lazy / IT-slow clinicians
• Cant be identified due to IT problems

10
Clinician needs to know

• That a patient is in a register
• What needs to be done
• Where to record it
• How to do it
• Easily, quickly, part of normal clinical process

11
Understanding the work

• Targets which need action eg recalls to clinics
• Combine targets (eg cholesterol and BP done by
  HCA)
• Work which can be done during consultation eg
  medication reviews
• Targets in the correct time frame understand
  the time-specific targets

12
Why doesnt it happen?

• Audit clinical encounters to find out who does
  what
• Use any available IT facilities to help with spot
  checks
• Take advantage of opportunistic encounters eg flu
  clinics
• Train non-clinical staff to look out for patients
  with apparent gaps, and offer them appointments
  or get them followed up

13
Full/high QOF points

• Identify the patients
• Do the work
• Record the data
• Run recall systems
• Log and chase DNAs
• Exception report
• Constantly monitor progress

14
Record the data

• Know how to use the computer
• Be able to differentiated between different
  screens, fields and ways of entering data
• Understand Read codes
• Use free text judiciously
• Follow referral and recall systems

15
Understand Read codes

• Codes beginning A-Z diagnostic
• Codes beginning with a number
• symptoms
• signs
• investigations
• procedures
• administration

16
Codes and terms

• Preferred term - Acute myocardial infarction
• Synonym - Heart attack
• Acronym - MI
• Read Code - G30..

17
Common coding errors - 1

• Family history as an actual disease
• History of a disease without a date of occurrence
  of disease
• A disease code with qualifying free text to
  indicate absence of a condition
• The date of entry instead of the date of
  occurrence

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Common coding errors - 2

• A diagnosis when symptoms would be more
  appropriate
• A procedure (syringing the ears) without
  associated morbidity (excess ear wax)
• A morbidity entered instead of an immunisation or
  test e.g. tetanus instead of tetanus
  immunisation
• Neonatal problems in a mothers record, or birth
  details in the babys record (e.g. Caesarean
  section).

19
Read codes

• Required Read codes available at
  http//www.primarycarecontracting.nhs.uk/145.php
  (or follow link from foot of http//www.paymoderni
  sation.scot.nhs.uk/gms/quality/index.htm)
• Be aware of changes to the Business Rules which
  dictate the QOF Read codes

20
Summary of changes from Version 8 and Version 8.5
of the QOF Business Rules Depression A new
denominator rule has been added to Indicator 1
(patients with CHD or diabetes) to
exclude patients with a current diagnosis of
depression.
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www.PrimaryCareInformatics.co.uk
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Full/high QOF points

• Identify the patients
• Do the work
• Record the data
• Run recall systems
• Log and chase DNAs
• Exception report
• Constantly monitor progress

27
Run recall systems

• The job of the recall clerk is to match patients
  in need of reviews or treatment
• With the correct clinician
• At suitable places, dates and times
• Who has the job(s) of getting the patient there
  (on time)? Should the practice remind patients?

28
Which recalls

• Identify all recall areas, including those done
  by individuals eg nurse-led clinics
• Calculate the numbers of patients in each disease
  area
• Find out how often each type of patient needs to
  be recalled routinely

29
Understanding the problems

• Identify the resources available
• GPs
• Nurse practitioners and nurses
• Health care assistants and phlebotomists
• Admin staff
• Plan the year 52 weeks, less
• Easter and Christmas period
• Half terms and main summer holidays

30
Identifying patients

• Searches
• Conditions
• Medication
• Test results or lack of any of these
• Recalls
• Plan how to log recalls
• Ensure old ones deactivated

31
How to handle patients with multiple conditions

• Identify various groupings eg diabetics with
  hypertension
• Flag patients to prevent multiple recalls
• Consider multiple problem data entry screens
  and/or clinics

32
Single or multiple chronic diseases

• Instead of calling by disease, recall by patient
  eg in the month of their birth
• Recall them into specific clinics, if one chronic
  disease only, or
• Recall them into multiple disease sessions
• Appointments for these range from 20 minutes
  upwards

33
Data entry

• Draw up recall data entry guidelines for
• Recall staff (administrative entries)
• Clinicians (clinical entries)
• Agree follow-up protocols
• How long to wait before second approaches
• Who should contact certain patients
• Complete other relevant entries eg medication
  reviews

34
Timing

• Ensure all new registrations/diagnoses have 1st
  invites to relevant clinics
• Ensure remaining patients have one-year (or less)
  recalls set
• No scripts to be given for more than a year

35
Monitoring recalls

• Check monthly recall figures against annual plan
• Have contingency plans for practical problems eg
  sickness
• Monitor QOF targets monthly, both for prevalence
  and for completion
• Target problem areas from November

36
Full/high QOF points

• Identify the patients
• Do the work
• Record the data
• Run recall systems
• Log and chase DNAs
• Exception report
• Constantly monitor progress

37
Log and chase DNAs

• How are the invitations recorded?
• What about verbal invitations?
• How are DNAs logged?
• How are DNAs followed up?

38
DNA Protocols

• Protocols for identifying and recording DNAs for
  receptionists and clinicians
• Decide when different types of patients are
  removed from this years (or permanent) recalls
• Invite exceptions, and exception report QOF
  patients (where appropriate)

39
Full/high QOF points

• Identify the patients
• Do the work
• Record the data
• Run recall systems
• Log and chase DNAs
• Exception report
• Constantly monitor progress

40
Exception report

• Practices may be called on to justify why they
  have excepted patients from the QOF and this
  should be identifiable in the clinical record.

41
Overriding principles for exception reporting - 1

• It should be based on clinical judgement with
  documented explanation
• Read code the exception code
• Free text the explanation/reason

42
CHD 7 The percentage of patients with coronary
heart disease whose notes have a record of total
cholesterol in the previous 15 months Excepted
from CHD quality indicators Patient unsuitable
9h01 Comment needle phobia
43
Overriding principles for exception reporting - 2

• No blanket exclusions each case should be
  considered on its own particular set of relevant
  factors
• For example
• Do not exclude all patients over a certain age eg
  no cholesterol tests for patients gt75
• Do not exclude patients with a certain condition
  eg no spirometry for patients with dementia

44
New patients/new diagnoses

• Patients newly diagnosed within the practice or
  who have recently registered with the practice
• Measurements made within three months eg take BP
• Delivery of clinical standards within nine months
  eg meet BP target

45
Time lines

• Patients registered or diagnosed on or after 1
  July must have their measurements/tests done
  within 3 months but their scores will not count
  towards the current QOF year.
• Patients registered or diagnosed on or after 1
  January will not count towards the current QOF
  targets.

46
Refusals

• Patients who have been recorded as refusing to
  attend review who have been invited on at least
  three occasions during the preceding twelve
  months.
• These patients are excluded from all indicators

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Invitations to attend must be patient specific

• Not a generic invitation on the right hand side
  of the script, eg to attend for flu vaccination
• Not a notice in the waiting room inviting
  particular groups of patient to attend, eg for
  asthma reviews

48
Informed dissent

• Where a patient does not agree to investigation
  or treatment (informed dissent), and this has
  been recorded in their medical records.
• Patients not responding to invitations or failing
  to arrive at appointments should not be
  classified as informed dissent

49
Inappropriate treatment

• Patients for whom it is not appropriate to review
  the chronic disease parameters due to particular
  circumstances eg terminal illness, extreme
  frailty.
• These patients are excluded from all indicators

50
Medication

• Patients who are on maximum-tolerated doses of
  medication whose levels remain sub-optimal
• Where a patient has not tolerated certain
  medication

51
Contraindications

• Patients for whom prescribing a medication is not
  clinically appropriate eg those who have an
  allergy, another contraindication or have
  experienced an adverse reaction.
• Where the patient has a supervening condition
  which makes treatment of their condition
  inappropriate eg cholesterol reduction where the
  patient has liver disease

52
Lack of facilities

• Where an investigative or secondary care service
  is unavailable.
• In the event a practice indicates an
  investigative or other specialist service is not
  available, agreement should be reached with the
  PCO

53
Causes of low exception reporting

• Lack of understanding of regulations
• Feeling that it is cheating or immoral
• Sense of not doing enough for the patient
• Sense of failing as a clinician
• Concern about labelling certain patients
• Not knowing how to record them
• Assuming that admin staff will do it

54
Full/high QOF points

• Identify the patients
• Do the work
• Record the data
• Run recall systems
• Log and chase DNAs
• Exception report
• Constantly monitor progress

55
Constantly monitor progress

• Check the prevalence of registers
• Use system reports and QMAS (when available)
  regularly fortnightly from at least November,
  weekly from January, and daily through March
• Periodically review understanding of QOF
  requirements amongst team members
• Target chosen areas rather than chasing ad hoc
  patches

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High value areas 1 365 points (55.7) out of
655 clinical domain points

• Blood pressure checks and management to required
  levels 148 points (CHD 26, stroke/TIA 7,
  hypertension 77, diabetes 21, CKD 17), plus 15
  points from the Organisational Domain for
  patients aged 45 having BP records every 5 years.

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High value areas 2 365 points (55.7) out of
655 clinical domain points

• Smoking status and cessation advice 74 points
  (68 points in the smoking area and 6 for teenage
  asthmatics), plus 11 points from the
  Organisational Domain for patients aged 15
  having their smoking status checked every 27
  months

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High value areas 3 365 points (55.7) out of
655 clinical domain points

• Cholesterol measurement and reduction 40 points
  (CHD 24, stroke/TIA 7, diabetes 9)
• HbA1c recorded and treated to 7.5 or less 31
  points,
• Anti-platelet or anticoagulant therapy 30 points
  (CHD 7, stroke/TIA 4, diabetes 4, atrial
  fibrillation 15)

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High value areas 4 365 points (55.7) out of
655 clinical domain points

• Use of a) ACE inhibitors/A2 antagonists, or b)
  ACE inhibitors/ARBs 24 points (a) CHD 7,
  diabetes 3 b) HF 10, CKD 4)
• Flu vacs 18 points (CHD 7, stroke/TIA 2,
  diabetes 3, COPD 6)

60
New QOF clinical areas 137 points

• Mental Health (new indicators) - 9 points
• Dementia - 20 points
• Depression - 33 points
• Chronic Kidney Disease - 27 points
• Atrial Fibrillation - 30 points
• Palliative Care - 6 points
• Obesity - 8 points
• Learning Disability - 4 points

61
Mental health (39)

• Register of patients
• with diagnoses of schizophrenia, bipolar disorder
  and other psychoses
• no longer a register of patients with severe
  mental illness consenting to regular reviews

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Clearer definition of register

• Check all existing patients
• Search again for other psychotic patients
• Ask Community Mental Health Team for a list of
  patients that they see

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Mental health

• Review every 15 months includes
• a check on the accuracy of prescribed medication
• a review of physical health including, where
  appropriate
• issues relating to alcohol or drug use
• smoking and blood pressure
• cholesterol checks
• risk of diabetes
• regular preventive care, eg cervical cytology

65
Recording the review

• In the review there should be evidence that the
  patient has been offered routine health promotion
  and prevention advice appropriate to their age,
  gender and health status

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Lithium patients

• In the therapeutic range in the past 6 months
  (normally 0.4 - 1.0 mmol/l, unless otherwise
  agreed locally)
• Serum creatinine TSH in preceding 15 months
• Check systems for extracting data from
  hospital/CPN letters

67
New indicator care plans 1

• Patients on the mental health register must have
  comprehensive care plans recorded which have been
  agreed with individuals, and their families
  and/or carers target 25-50 (6)

68
CPA

• If a patient is treated under the care programme
  approach (CPA), a documented care plan discussed
  with their community key worker is acceptable for
  the QOF

69
Care plans

• 1. Patients current health status and social
  care needs expectations
• 2. How socially supported the individual is
• 3. Co-ordination arrangements with secondary
  care and/or mental health services and the
  services actually being received.
• 4. Occupational status
• 5. Early warning signs
• 6. The patients preferred course of action
  (discussed when well) in the event of a clinical
  relapse

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New indicator review DNAs

• Patients who fail to attend for their annual
  reviews must be followed up within 14 days of
  non-attendance by the practice team (or their
  care workers can be contacted) 40-90 (3)

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14-day follow-ups

• Recall patients/make appointments
• When patients DNA, have system for follow-ups
  which involves
• Contacting care worker/carer/patient
• Adding DNA code
• Adding follow-up code after the DNA code
• Recalling patient for next suitable appointment
  (where appropriate)

74
Monitoring mental health

• Check practice understanding of reviews
  (medication, physical health and co-ordination
  with secondary care)
• Check monitoring of tests, and systems for
  non-compliance
• Extract secondary care data

75
New clinical areas

• Palliative care
• Dementia
• Depression
• Chronic kidney disease
• Atrial fibrillation
• Obesity
• Learning disabilities

76
Palliative care (6)

• A complete register of patients aged 18 in
  need of palliative care/support care, wef 1 April
  2006 (3)
• This is not limited to cancer patients, but
  includes any patient needing palliative care
• Having patients on the register at any time
  during the year qualifies no prevalence
• Multidisciplinary practice case reviews of all
  such patients at least 3 monthly (3)

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Examples of Read codes

• Palliative care
• Specialist palliative care
• Specialist palliative care treatment outpatient
• Specialist palliative care treatment daycare
• On gold standards palliative care framework
• DS 1500 Disability living allowance (terminal
  care) completed

• ZV57C
• 8BAP.
• 8BAT.
• 8BAS.
• 8CM1.
• 9EB5.

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Case reviews

• Ensure that
• Each patient has a management plan as defined by
  the practice team and that decisions are acted
  upon by the most appropriate member of the team
• The management plan includes preference for place
  of care
• The support needs of carers are discussed and
  addressed where ever reasonably possible.

79
Evidence

• The practice should submit written evidence to
  the PCO describing the system for initiating and
  recording case reviews
• The register will be extracted by QMAS, but not
  the reviews
• But record them anyway!

80
Dementia (20)

• Register of patients with dementia (5)
• Diagnosis can be based on GP opinion
• Review psychogeriatric referrals
• Ask secondary care for a list of their current
  case load
• Ask local care homes and nursing home
• Ask the district nurses and CPNs

81
Dementia review

• Patients reviewed in previous 15 months 25-60
  (15)
• An appropriate physical and mental health review
  for the patient
• If applicable, the carers needs for information
  commensurate with the stage of the illness and
  his or her and the patients health and social
  care needs
• If applicable, the impact of caring on the care
  giver
• Communication and co-ordination arrangements with
  secondary care (if applicable)

82
Depression (33)

• A register of patients with diabetes and/or
  heart disease who have also been screened for
  depression (using two standard questions) in the
  last 15 months 40-90 (8)
• A register of patients aged 18 newly diagnosed
  with depression (during that QOF year) who have
  had the severity of their illness assessed using
  validated assessment tools (excludes post-natal
  depression) 40-90 (25)

83
Nice Quick Reference Guide to Depression

• During the last month, have you often been
  bothered by feeling down, depressed or hopeless?
• During the last month, have you often been
  bothered by having little interest or pleasure in
  doing things?

84
Assessment tools

• Validated severity measures for use in primary
  care setting (type must be recorded in records)
• The Patient Health Questionnaire (PHQ-9) Free
• The Beck Depression Inventory Second Edition
  (BDIII)
• The Hospital Anxiety and Depression Scale (HADS)

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PHQ-9
Over the last 2 weeks, how often have you been
bothered by any of the following problems?

• 1. Little interest or pleasure in doing things
• 2. Feeling down, depressed, or hopeless
• 3. Trouble falling or staying asleep, or sleeping
  too much
• 4. Feeling tired or having little energy
• 5. Poor appetite or overeating
• 6. Feeling bad about yourself - or that you are a
  failure or have let yourself or your family down

• 7. Trouble concentrating on things, such as
  reading the newspaper or watching television
• 8. Moving or speaking so slowly that other people
  could have noticed. Or the oppositebeing so
  fidgety or restless that you have been moving
  around a lot more than usual
• 9. Thoughts that you would be better off dead, or
  of hurting yourself in some way

Not at all / several days / more than half the
days / Nearly every day
86
Chronic kidney disease (27)

• A register of patients aged 18 and over (levels
  3-5) (6)
• BP measured in the last 15 months 40-90 (6)
• BP 140/85 or less (not to be confused with the
  diabetic limit of 145/85) 40-70 (11).
• Patients with hypertesion on angiotensin
  converting enzyme inhibitors (ACE-I) or
  angiotensin receptor blockers (ARB) in the
  previous 6 months (prior to year end) 40-80 (4)

87
CKD

• US National Kidney Foundation classified in 5
  stages, only stages 3 5 are included.
• Affects 5 of population
• Commoner in black and south east Asian
• Treating blood pressure well prevents progression

88
CKD codes
89
eGFR

• eGFR does not feature directly in QoF or QMAS,
  but it is a diagnostic tool to help build the CKD
  register
• Stage 3-5 GFR (eGFR) lt 60ml/min/1.73m2

90
Atrial fibrillation (30)

• Register of AF patients (5)
• Diagnoses from 1 April 2006 confirmed by ECGs or
  specialist opinions (referral alone insufficient)
  up to 3 months prior or 12 months after
  diagnosis 40-90 (10)
• Patients treated with anti-coagulants or
  anti-platelets during the previous 6 months
  40-90 (15)

91
Checking AF

• System for ensuring ECGs done or patients
  referred and seen (or exception reported)
• Check anticoagulation patients for missing AF
  diagnoses

92
Obesity (8)

• Obesity a register of patients aged 16 who have
  BMIs of 30 or more, measured in the last 15
  months (8)
• No way of checking prevalence measure as many
  patients as possible (height and weight) as this
  area is set to expand

93
Learning disabilities (4)

• Create a register of patients aged 18
• Combine with DES
• Ask Community Mental Health Team for their list

94
Learning disabilities definition

• A significantly reduced ability to understand new
  or complex information, to learn new skills
  (impaired intelligence), with
• a reduced ability to cope independently (impaired
  social functioning)
• which started before adulthood (18 years), with a
  lasting effect on development.

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Clinical indicators - general
96
Blood pressures

• 15 monthly for CHD, stroke, diabetes
• 9 monthly for hypertension
• Maximum BP levels 150/90, except for diabetics
  145/85 and kidney disease 140/85
• 5 yearly for other patients aged 45
  (organisational domain 15 points)

97
BP rules

• Be aware of difference between CDM BPs and
  routine 5-year checks
• Do not measure unnecessarily and generate
  inappropriate expectations
• Clinicians must take responsibility for the
  outcomes of BP checks

98
Smoking status

• Once only for non-smokers, but must be entered
  after diagnosis of first qualifying disease
• Every 15 months if
• Smokers or ex-smokers, and have
• CHD, stroke/TIA, hypertension, diabetes, COPD
  and/or asthma (33 points)
• Are asthmatics aged 14-19 (even if non-smokers)
  (6 points)

99
Smoking status

• All other patients, aged 15 every 27 months
  (once only for non-smokers) (Records 11 pts)
• Train receptionists to distribute simple
  questionnaires and enter returned data
• Remind practice team of need to collect for
  over-75s include with flu jabs
• Include questionnaire slips with repeat
  prescriptions

100
Smoking cessation advice

• Every 15 months for smokers with CHD, stroke/TIA,
  hypertension, diabetes, COPD and/or asthma (35)
• Literature and appropriate therapy made available
  to all smokers (Information for Patients area 2
  points)

101
Flu immunisations

• Qualifying conditions
• CHD
• Stroke or TIA
• Diabetics
• COPD (but not asthma)
• Season runs September March

102
Flu clinics

• Use these to check QOF data
• Have staff available to check heights weights,
  smoking status, and give smoking cessation advice
• Not good for BPs as raised because of
  jabs/thought of jabs

103
Cholesterol

• Every 15 months for
• CHD
• Stroke or TIA
• Diabetes
• 5 mmol/l or less

104
Clinical indicators disease specific
105
Coronary heart disease (89)

• CHD register
• Angina diagnoses since 1/4/03 referred for
  exercise testing and/or assessment (3 months
  prior to, or 12 months after, diagnosis)
• Aspirin, alternative anti-platelet or
  anti-coagulant therapy, as appropriate
• On beta-blockers (within the last 6 months)
• On ACE inhibitor or A2 antagonists (within the
  last 6 months) if MI after 1/4/03

106
Monitoring CHD - 1

• Angiograms system for capturing results
• Aspirin (including OTC)
• Ensure reminders for OTC queries to patients
• Consider prescribing to ensure that patient
  compliance is monitored
• OTC entries must be updated (within the last 15
  months)

107
Monitoring CHD - 2

• Anti-platelet anti-coagulant therapies check
  all patients on aspirin, clopidrogel or warfarin
  have appropriate diagnoses
• Beta-blockers must be taken within the 6 months
  prior to 31/3/07
• ACE inhibitors (or A2 antagonists) if MI after
  1/4/03
• System for identifying new MIs
• Must be taken within the 6 months prior to
  31/3/07.

108
New indicators Heart failure (20) (previously
LVD)

• HF register patients with heart failure (4)
  HF1.1 Rationale Prevalence expected to rise 100
• Do not use 1O1 (letter O) Heart failure
  confirmed - must be G58

109
Heart failure

• Diagnoses since 1 April 2006 of suspected heart
  failure (eg 1J60) confirmed by an echocardiogram
  or by specialist assessment (3 months prior 12
  months after addition to register) 90 (6)
• Currently treated with an ACE inhibitor or,
  subsequently, ARB (Angiotensin Receptor Blocker)
  80 (10)

110
Monitoring HF

• Echocardiograms system for capturing results
• On ACE inhibitors or ARBs check patient
  compliance within the 6 months prior to year end.

111
Stroke or TIA (24)

• Presumptive strokes since 1/4/06 confirmed by
  referral for specialist investigation (3 months
  prior to, or 12 months after, diagnosis)
• Aspirin or other anti-platelet or anti-coagulant
  therapy, for patients with non-haemorrhagic
  strokes or TIA (all need excepting if not
  appropriate)

112
Monitoring strokes or TIAs

• Referrals must be recorded using specified Read
  codes
• Anti-platelet anti-coagulant therapies as for
  CHD
• Aspirin (OTC) as for CHD

113
Hypertension (83)

• Patients with established hypertension
• Based on 3 readings
• Exclude episodes of transient raised BP
• Exclude raised BP during pregnancy
• Prior to diagnosis, use codes for raised blood
  pressure

114
Monitoring hypertension

• BPs must be checked on/after 1 July
• Systems for recalling patients with
• No BPs
• BPs too high
• Protocols for treating/exception reporting
  patients with raised BP

115
Diabetes (93)

• Register must show Type 1 or 2 (new Read codes)
• Diabetics aged 17
• Excludes diabetes during pregnancy
• Those with proteinuria or micro-albuminuria
  should be on ACE inhibitors or A2 antagonists (in
  6 months prior to year end)
• HbA1c (three levels)
• Checked
• 10 or less (or local lab. equivalent)
• 7.5 or less (was 7.4)

116
Diabetes Code Changes
117
Diabetic checks

• Micro-albuminuria
• eGFR (estimated glomerular filtration rate) or
  serum creatine
• BMI
• Retinal screening
• Peripheral pulses
• Neuropathy testing

118
Monitoring diabetes (1)

• Review clinic protocols to ensure these match the
  QOF requirements and spot check entries
• Ensuring checking and recording of test results
• Check diagnoses for proteinuria or
  micro-albuminuria (significant results alone are
  inadequate)

119
Monitoring diabetes (2)

• Protocols for recalling or exception reporting
  raised HbA1cs
• Ensure BMIs correctly recorded
• Retinal screening should be PCO-approved service
• Peripheral pulses and neuropathy testing check
  whether done by the practice or elsewhere

120
COPD (33)

• With diagnosis confirmed by spirometry, although
  no longer necessary for long-standing/obvious
  cases (80 target)
• Patients with both asthma and COPD can now be on
  both registers
• Record in the last 15 months of
• FeV1
• Inhaler technique (patients not on inhalers
  should be exception reported)

121
Monitoring COPD

• Ensure all possible COPD diagnoses confirmed by
  spirometry (3 months prior to, or 12 months
  after, diagnosis), or patients exception reported
• Check systems for checking and recording FeV1 and
  inhaler technique need to be done annually

122
Asthma (45)

• Asthmatics who have ALSO been prescribed
  asthma-related drugs in the last 12 months
• Practice will also have to report the numbers of
  inactive asthmatics ie no current asthma
  medication
• Aged 8, with measures of variability or
  reversibility
• Asthma review in the preceding 15 months

123
Summary of Asthma Review

• Assess symptoms
• "In the last month
• Have you had difficulty sleeping because of your
  asthma symptoms (including cough)?
• Have you had your usual asthma symptoms during
  the day (cough, wheeze, chest tightness or
  breathlessness)?
• Has your asthma interfered with your usual
  activities e.g. housework, work/school etc?"
• Measure peak flow
• Assess inhaler technique
• Consider personalised asthma plan

124
Monitoring asthma

• Check understanding of inclusion in asthma
  register
• If no longer asthmatic, but on asthma medication
  (eg for hay fever), add Read code for Asthma
  resolved
• Check components of asthma review

125
Smoking anomaly
126
Epilepsy (15)

• Identify patients aged 18 currently on
  medication (patients without drug medication will
  not be included)
• Patients aged 18 with records in the past 15
  months of
• Seizure frequency
• Medication reviews (face-to-face, with
  patient/carer)
• Convulsion free for 12 months prior to a review
  in the last 15 months

127
Monitoring epilepsy

• Not all patients on epilepsy medication are
  epileptic check for diagnoses
• Seizure frequency/convulsion free system for
  checking hospital reviews
• Medication reviews plan these to ensure time to
  find out about seizure frequency
• Use code for epilepsy resolved

128
Hypothyroidism (7)

• Patients with hypothyroidism and taking thyroxine
• TFTs every 15 months

129
Cancer (11)

• Exclude non-melanotic skin cancers
• For patients diagnosed within the past 18 months
  (of the QOF year end), practice review within 6
  months of notification (8BAV)
• Support needs (if any)
• Review of co-ordination with secondary care

130
Monitoring cancer diagnoses

• System for
• Capturing diagnoses
• Doing practice reviews
• Entering correct code

131
Holistic care (20)

• Based on clinical domain
• Calculated by achievement in 3rd worst area

132
Queries

• Go to
• http//www.paymodernisation.scot.nhs.uk/gms/qualit
  y/docs/ExceptionguidanceMarch06_final.doc
• http//www.paymodernisation.scot.nhs.uk/gms/natref
  /qual_def/faqs_index.htm

133
The non-clinical domains
134
Organisational domain (181)

• Records information (87)
• Information for patients (5.5)
• Education training (31)
• Practice management (17.5)
• Medicines management (40)

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138
BP (15)

• R11/17 The blood pressure of patients aged 45
  and over is recorded in the preceding 5 years for
  at least
• 65 of patients (10)
• 80 of patients (5)

139
Summaries (52)

• R15/18/20 The practice has up-to-date clinical
  summaries in
• at least 60 of records (25)
• at least 80 of records (8)
• at least 70 of records (12)
• R19 80 of newly registered patients have had
  their notes summarised within 8 weeks of receipt
  (7)

140
Ethnicity (1)

• R21 Recording ethnic origin in 100 of new
  registrations from 1 April 2006
• Refusals can be recorded

141
Smoking (11)

• R22 The smoking status of patients aged 15 is
  recorded every 27 months (40-90), except that
  patients who have never smoked need have it
  recorded only once

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145
Significant event reviews

• E7 12 in the last 3 years (4)
• E10 3 in the last year (3)
• Any death occurring in the practice premises
• New cancer diagnoses
• Deaths where terminal care has taken place at
  home
• Any suicides
• Admissions under the Mental Health Act
• Child protection cases
• Medication errors
• A significant event occurring when a patient may
  have been subjected to harm, had the
  circumstance/outcome been different (near miss)

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150
Medication reviews

• M11/12 Medication reviews every 15 months
  (minimum 80 standard)
• Patients on 4 or more repeats (7)
• Patients on any repeats (8)

151
Patient experience and additional services
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154
Surveys 1 2

• Survey done annually (25)
• Reflection and action plan (20)
• 1. Summarises the findings of the survey.
• 2. Summarises the findings of the previous years
  survey.
• 3. Reports on the activities undertaken in the
  past year to address patient experience issues.

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Surveys 3

• Reflection and action plan (30)
• 1. Sets priorities for the next 2 years.
• 2. Describes how the practice will report the
  findings to patients
• 3. Describes the plans for achieving the
  priorities, including indicating the lead person
  in the practice.
• 4. Considers the case for collecting additional
  information on patient experience, for example
  through surveys of patients with specific
  illnesses, or consultation with a patient group

157
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159
Smears Screening management (7)

• CS7 The practice has a protocol that is in line
  with national guidance and practice for the
  management of cervical screening, which includes
  staff training, management of patient call/
  recall, exception reporting and the regular
  monitoring of inadequate smear rates

160
New Scottish Directed Enhanced Services 2006
161
New Directed Enhanced Services

• Cardio-vascular Disease (CVD) Dataset
• Cancer Referral
• Adults with Learning Disabilities
• Carers
• Access

162
Cardio-vascular Disease (CVD) Dataset

• Compile a CVD risk dataset
• on all patients between 45 and 64 years of age
• for whom there are no BP or smoking status
  records since 1 April 2001
• based on a search run on 1 April 2006
• Apply appropriate clinical interventions

163
Dataset of selected CVD risk factors

• Age and gender
• Height and weight gt BMI
• Past medical history
• CHD, stroke, diabetes, hypertension
• Family history
• Heart disease, diabetes
• Tobacco use
• Current smoker, ex-smoker, never smoked
• Blood pressure

164
Cancer referrals

• Conduct a review of all new cancer cases
  (excluding non-melanotic skin cancers) diagnosed
  in the year preceding 1 April 2006
• Look at the whole patient pathway
• Record whether new cases were referred
• Urgently, by local protocol (if available) or
  routinely
• Review and discuss the appropriateness of the
  mode of referral for each case
• Not compulsory to review cases of deceased
  patients

165
Adults (18) with Learning Disabilities

• Identify
• Cause of learning disabilities
• Severity of disability (mild, moderate, severe,
  profound)
• Living support arrangements
• Cervical screening status (removed from
  requirements)
• Any other major medical problems including
• epilepsy
• visual auditory impairment
• behavioural problems

166
Liaison

• Liaise with relevant outside agencies, by
• Identifying one person from within the practice
  team to act as an appropriate liaison officer
• Ensuring appropriate contact with relevant
  outside agencies
• Identify and address, if possible, any barriers
  to access for people with learning disabilities
  to treatment and appropriate screening (this
  could be done through an annual meeting with
  outside agencies)

167

• Confirm to NHS Boards by the end of December 2006
  that
• The learning disabilities registers have been set
  up and
• Liaison and identification measures have been
  taken

168
Carers

• A carer is someone, who, without payment,
  provides help and support to a partner, child,
  relative, friend or neighbour, who could not
  manage without their help. This could be due to
  age, physical or mental illness, addiction or
  disability.
• A young carer is a child or young person under
  the age of 18 carrying out significant caring
  tasks and assuming a level of responsibility for
  another person, which would normally be taken by
  an adult.
• (Princess Royal Trust www.carers.org)

169
Aims of the DES

• To ensure that the health and social needs of
  carers are identified and (met) that steps are
  taken to maximise the quality of life and care
  for both the carer and the cared for person,
  fully recognising carers as key partners and
  providers of care.

170
Requirements

• Produce and maintain a register of people who are
  carers, and flag their medical records
• Liaise with relevant outside local carer agencies
  (if they exist) and social work services by
• Identifying one person from within the practice
  team to act as an appropriate liaison officer
• Agreeing a referral process for referring carers
• Co-operate with any relevant agencies in any
  initiative (such as mailshots, all to be funded
  by these agencies) designed to alert carers to
  the support that they offer.

171

• Confirm to NHS Boards by the end of December 2006
  that
• The registers have been set up and
• Liaison and other requirements have taken place

172
Access defined - 1

• Direct contact (face-to-face, by phone or another
  means such as email) where
• professional, clinical advice is sought and given
  within 2 working days in accordance with the
  clinical needs of the patient and
• a professional, clinical opinion and/or diagnosis
  is required in order to determine a further
  course of action e.g. to treat to refer or to
  provide professional advice.

173
Access defined - 2

• Professional means a doctor, nurse or health
  visitor or other health care professional in the
  practice with which the patient is registered,
  who is competent to deal with the patients
  clinical needs.
• 48 hours means 2 working days, where a patient
  requests a consultation in that time, during the
  normal working hours of the practice, where
  consultations are available as published by the
  practice.
• Patients mean those (including temporary
  residents) who are registered with the practice.

174
48-hr requirements one or more of

• Open access (patients are seen on the same day
  without an appointment)
• Advanced Access (or equivalent) approach with
  same day appointments.
• Practice Accreditation, Training Practice
  Accreditation, or QPA have been awarded and the
  access criteria have been achieved
• Telephone (or email) access to a member of the
  primary care team for professional advice or a
  consultation within 48 hours e.g. a booked
  appointment in a doctor or nurse led telephone
  surgery.
• Formally established arrangements for triage by a
  doctor or a nurse by phone or face to face.
• Arrangements for patients to be seen by a doctor,
  nurse or other healthcare professional within 48
  hours (or sooner where there is a clinical need).

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Exclusions

• Where the patient
• does not wish to have contact or be seen within
  48 hours
• specifies a particular professional or
  individual, where an appropriate, alternative
  professional is available within 48 hours.
• is offered access within 48 hours but declines
• Requests for emergency and urgent treatment which
  should be dealt with sooner
• Pre-planned courses of elective treatment or care
  programmes
• Outside the normal working hours of practice.
• Planned closures e.g. public holidays or staff
  training.

176
http//www.show.scot.nhs.uk/sehd/

• http//www.show.scot.nhs.uk/sehd/pca/PCA2006(M)08.
  pdf see Annex A for revised contract 18 April
  2006
• http//www.show.scot.nhs.uk/sehd/pca/PCA2006(M)07.
  pdf - revisions to new enhanced services 18
  April 2006