Consolidated Funding Framework (CFF) 2017-19 Year 2 – 2018-2019 Practice sign up form Practice Name Practice Number Locality Practice Declarations As part of the CFF, practices are to identify a Lead for the below areas: Please provide the appropriate information, and if during the CFF these positions change within the practices, practices will need to alert the CCG Commissioning team on and advise of the same information for the new lead. Lead role: GSF Co-ordinator Lead Name Position in Practice Contact email Contact Telephone number Lead role: Diabetes Lead Lead Name Position in Practice Contact email Contact Telephone number Lead role: Cancer Champion Lead Name Position in Practice Contact Contact Telephone number
New care plans = 70% Review of care plans = 30% number of patients Number with a care plan Number without a care plan 100 20 80 Example New care plans = 70% (of 80) = 56 care plans Review of care plans = 30% (of 20)= 6 care plans 2) Completing Care Plans 2.1 Which Care Plan? SystmOne - Ardens Users SystmOne - Non Ardens Users EMIS Web Use the relevant condition specific templates to capture key information. Use the LTC review template to help you identify which condition specific plans the patient needs. Click on future care planning Click on Generic Care Plan (This is the foundation document) - make sure you select the code from the drop down box Click on Specific Care plan - this will take you to the plans for specific conditions Signpost patients (where appropriate) to self-management support on the Health in Herts webpages For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Ensure patients are correctly with a GSF stage / Frailty code, where appropriate. Signpost patients (where appropriate) to support on the Health in Herts webpages. For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet to explain how this works Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Ensure patients are correctly coded with a GSF stage / Frailty code, where appropriate. Signpost patients (where appropriate) to support on the Health in Herts webpages. For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet management management
This page left intentionally blank Post Death Audits Primary Care - CFF 18/19 Background Post Death Audits (PDA) support the CCG to identify where gaps exist in the palliative and end of life care pathway. They provide the CCG with a snapshot of issues with current provision and areas for improvement. This helps to improve the quality of services for patients. In 2017/18 practices were asked to identify if the patient was a care home / nursing home resident and which care home this was. This has enabled us to identify care homes that were sending residents to hospital when they were end of life rather than keeping them at the home. We have
to the HPFT share care protocol for physical health checks for people with SMI – Read codes SystmOne (CTV3 Code) EMIS & Vision (v2 Code) SNOMED Concept ID Code (SNOMED replaces Read CTV3 & v2 in all GP systems during 2018) Mental health annual physical examination done XaJON 9H9 408404002 and action plan Goal identification 67L 225294001 Review of Patient Goals 8CMX 775501000000108 Care Plan documentation SystmOne - Ardens SystmOne - Non Ardens Users EMIS Web Use the relevant condition specific templates to capture key information. Use the LTC review template to help you identify condition specific plans the patient needs. Click on future care planning Click on Patient Goals and set goals relating to physical health with patient Signpost patients (where appropriate) to support on the Health in Herts webpages Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES to set patient goals. Signpost patients (where appropriate) to support on the Health in Herts webpages. Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous as part of the avoiding unplanned admissions DES to set patient goals. Signpost patients (where appropriate) to support on the Health in Herts webpages. management management