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.

Using the frameworks: blood pressure optimisation

AHSNs are delivering a blood pressure optimisation programme aiming to prevent heart attacks, strokes, and vascular dementia in patients with hypertension.

As part of this programme, UCLPartners’ Proactive Care Framework for hypertension will be used to support Primary Care Networks (PCNs) to optimise clinical care and self-management of people with the condition. Read more about this work.

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:

Piloting the frameworks

The West of England AHSN supported piloting the frameworks by working with a small number of surgeries on asthma and type 2 diabetes projects in 2021/22. The implementation resources available for participating practices included access to motivational coaching, facilitation of team meetings to discuss project goals and workforce changes and signposting to clinical training and resources. Read more about our work with a local CCG on diabetes care.

What other resources are available?

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