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Disease Prevalence Quality Improvement Programme

These quality improvement programmes begin with a needs assessment so we properly understand the needs of your PCN and CCG. We then build a bespoke package comprised of Attend2 platforms and QOF Disease Prevalence tools as well as Clinical Pharmacist support which can be used for patient coding and training. The programme is delivered incrementally over a period of 6-12 months depending on the PCN preference.

The programme aims to help PCNs and CCGs better manage the care of patients with long term conditions, particularly in the wake of COVID-19 and the backlog of care that remains. Clinical capacity is increased while resources such as our Attend2 and QOF Disease Prevalence platforms allow a deep interrogation of practice registers to prioritise patients according to need.

Delivery of the full 12-month programme is divided into 4 phases.

Disease Prevalence Quality Improvement Programme

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    How it works?

    Phase 1

    Phase 1

    Phase 1 begins with a focus on the 6 CVD domains within QOF. A personalised QOF Disease prevalence platform will be provided, casting a lense of all patients across the population to identify those meting the QOF criteria while not being recorded on disease registers. A clinical Pharmacist will support by training PCN teams on the platform and begin actioning the review and addition of patients onto practice registers through a coding review. As part of the ongoing QI cycle, outcomes will be measured through Revalidation reports. Remote consultation support is also available for ongoing assistance and clinical outcomes.

    ATTEND2 PLATFORM

    ATTEND2 PLATFORM

    Supplementing each of the 4 phases, the programme is underwritten by a chosen Attend2 platform in a chosen long term condition. Attend2 platforms enable national guidelines and best practice to be reinforced within general practice. Where gaps in care are identified, the Attend2 platforms allow action plans to be generated, clinical work to be implemented and improvements measured.

    Phase 1
    Phase 2

    Phase 2

    Phase 2 focuses on the 4 Respiratory and MSK QOF domains. Again, a personalised QOF Disease prevalence platform will be provided, allowing these patient cohorts to be reviewed and assessed for their suitability for register inclusion. The clinical Pharmacist will support by training PCN teams on the platform and begin actioning the review and addition of patients onto practice registers through the coding review. Continuing the ongoing QI cycle, outcomes will be measured through Revalidation reports. Remote consultation support is also available for ongoing assistance and clinical outcomes.

    ATTEND2 PLATFORM

    ATTEND2 PLATFORM

    Supplementing each of the 4 phases, the programme is underwritten by a chosen Attend2 platform in a chosen long term condition. Attend2 platforms enable national guidelines and best practice to be reinforced within general practice. Where gaps in care are identified, the Attend2 platforms allow action plans to be generated, clinical work to be implemented and improvements measured.

    Phase 2
    Phase 3

    Phase 3

    Phase 3 concentrates on the 5 high dependency and other LTC domains. The personalised QOF Disease prevalence platform will be provided and trained out through staff so patient groups can be reviewed and added to registers supporting care and practice income. Building on the programme QI cycle, outcomes will be measured through Revalidation reports and progress evaluated. Remote consultation support is also available for ongoing assistance and clinical outcomes. Coding support within these domains is currently being trialled.

    ATTEND2 PLATFORM

    ATTEND2 PLATFORM

    Supplementing each of the 4 phases, the programme is underwritten by a chosen Attend2 platform in a chosen long term condition. Attend2 platforms enable national guidelines and best practice to be reinforced within general practice. Where gaps in care are identified, the Attend2 platforms allow action plans to be generated, clinical work to be implemented and improvements measured.

    Phase 3
    Phase 4

    Phase 4

    The final phase of the programme looks into the remaining 5 domains surrounding mental health and neurology. A fresh QOF Disease prevalence platform will be provided covering these 5 domains. Our Clinical Pharmacist will work in partnership with PCN teams, reviewing patient and training out best practice for patient addition within these domains. The QI cycle will continue with action evaluated and reflected upon through the included revalidation reports. Remote consultation support is also available for ongoing assistance and clinical outcomes. Currently there is no coding support available for these domains.

    Phase 4
    Ongoing support

    Ongoing support

    Following the completion of the year 1 package, it is our intention to continue this annual support, assessing the new needs and demands of the PCN as the healthcare landscape changes and new challenges arise. The process will repeat with a new needs analysis and proposal before initiating the new QI programme of work. Repeating the process, Interface will provide 12-month support packages year on year for PCNs and CCGs across the country to drive healthcare standards in log-term conditions and provide additional clinical resource and training for PCNs and CCGs and their teams.

    Ongoing support
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    Find out more