Managing long term condition patients during the pandemic

26th Jun 2020

The following is available to download here, should you wish to print/share.

Coronavirus and its impact on general practice has significant implications now and moving forward. One aspect which it has accelerated is how we can use other areas of communication (e.g. phone, SMS, video & emails) to manage the same problems which we previously would have called the patient in for.
There are several advantages to remote access, for example convenience of use, managing housebound patients, empowering patients to look after their condition, being able to see patients who just can’t have face to face due to their busy jobs.

Here are some practical suggestions on how your surgery can look to deal with chronic disease call/recall using PatientChase, often without having to physically see them.

Types of communication
Letters – Consider using these if you want to send information on how a patient can self- manage certain aspects of their conditions.
Telephone – most convenient and easiest to use. Majority of QOF can be managed this way as described later.
Video – has set up issues especially with the elderly but can be useful for certain case scenarios e.g. showing a patient how to use an inhaler properly.
Emails – Very useful when sending out campaigns e.g. smoking cessation advice and also contacting patients once you are happy with the IG of how to use this with patients.
SMS – Useful to show links to patients relevant to their condition eg inhaler technique videos and what diet they should be following. Please ensure they have a smartphone on their side otherwise you need to email them the link instead.

PatientChase can directly contact and code patients via letter, SMS or email and should you decide to contact patients by phone, the software can batch record into EMIS that you have contacted them by phone.
And remember, you can filter out patients in PatientChase that you don’t need to contact based on them having already met their QOF targets or have had a ‘review done’ code entered in their records.

Suggestions based on 2020/1 QOF criteria
Register Searches Only
These are conditions where you just need to make sure you maintain a register.
Peripheral Artery Disease.
Chronic Kidney Disease (These patients can of course be identified using the ‘review done’ code should your practice still wish to review them. Often they are reviewed alongside any other conditions they may have). 
Learning Disability (Consider calling these patients up. This offers a more personal touch and often gets a better response).
Again, the patients on any of the registers above patients can be targeted and reviewed as part of a review of their other conditions.

Review notes
These are conditions where the clinician needs to review the notes of the patient list and then decide if the patient needs to come in for a review. These can be contacted however alongside any other conditions they may have.

Heart Failure.
Atrial Fibrillation.

Email and letter campaigns
Areas in the QOF where you need to inform a certain population to educate them about their condition or habit. For QOF this mainly applies to Smoking Advice. With PatientChase you can automatically batch email your patients and insert a coded record of the email into EMIS.
Asthma Action plans and Mental Health Care Plans can also be emailed to patients this way.

Need to call patients in
There are a few conditions where a physical examination is required so booking face to face is essential. However there is no reason why part of this review can’t also be done remotely.
Diabetes for checking feet (though information about foot care could be sent by SMS, email or letter).
Chronic Obstructive Pulmonary Disease for spirometry.
Cervical smears.

Remote consultations
One of the main strengths of PatientChase is the ability to group together conditions so the patient is contacted only once and seen as few times as possible. The following can be quite comfortably seen via a remote consultation (EMIS has partner companies providing this), but you need to ensure the patient has the correct equipment on their side to help the process. This can be via video or telephone, whatever is easier for your surgery and the patient to set up. We’d recommend video especially for Asthma where inhaler technique can be reviewed.
Asthma (video preferred).
Atrial Fibrillation (after clinician has reviewed the notes) Cancer.
Chronic Obstructive Pulmonary Disease.
Coronary Heart Disease.
Dementia (advise a carer to be present for the consultation so video would be preferred to have a group chat).
Heart Failure (after clinician has reviewed the notes).
Mental Health.
Rheumatoid Arthritis.
Stroke and TIAs.

A useful resource to form the start of a remote consultation flow for COPD and Asthma can be found here which is also a good resource to visit how to risk stratify patients using primary care data.

Blood Pressures and BMIs
For patients who need a blood pressure monitor we’d encourage them to get their own blood pressure monitor and do home blood pressure monitoring.
See this link to around home blood pressure monitoring:
For BMIs please ask the patient to tell you their weight and height. Although not as accurate as surgery scales the importance is to use the same scales and notice the difference in weight over time. There are several low cost Bluetooth scales on the market which are good as they automatically upload the weight to smartphones.

Peak Flow Meters
Patients should be prescribed peak flow meters and keep a track of their peak flow to help with the review but also empower them to understand what they need to do when their readings drop. is an excellent resource for patients with Asthma.
Information about the action plan which can be discussed remotely with the clinician can be found here:

Blood Tests
Blood tests need to be organised prior to a consultation and the process is different for different surgeries. However this will need a face to face with a phlebotomist, nurse, HCA or other certified professional.

Flu jabs
These require face to face. PatientChase has the ability for GPs to focus on subsets of populations which might be useful for surgeries during the flu campaign.

Working remotely on QOF is something surgeries are seriously considering and doing where possible as a way forward to help achieve targets but in a way which is better suited for patient needs. Consider the fact that the pandemic has heightened concerns patients have about their underlying conditions which means that they are more likely to engage in caring for themselves, even if this is not in a practice setting. This is an opportunity to engage more with patients who historically were less motivated or pro-active in managing their own health. While there is huge focus on COVID-19, the fact remains patients still have other conditions which still need managing. Doing so now will ease the pressure on the time when surgeries become more open to patients attending.

The most useful and user friendly software that I have encountered in over 30 years of working with management systems.

Cheryl Barton, Data Manager – Bramblys Grange Medical Practice, Hampshire

I am so glad that we as a practice have purchased PatientChase – it has completely revamped our recall system, has been invaluable during flu recall season and more importantly shows us where the ‘holes’ are when we get to near the end of the QoF year. Many thanks!

Jackie Hogg, Clinical Data Manager – The Baffins Surgery, Portsmouth

PatientChase is an excellent product of which I think as soon as you purchase it you will ask yourself ‘how ever did I cope without it?!

Rachel Mardlin, Health Informatics Facilitator – Sheffield University Health

This product will make my QOF staff member’s job so much simpler and is a quarter of a QOF point for me

GP, Newcastle

This is exactly what we’ve been looking for

PM, Cambridge

PatientChase is extremely user friendly and the support provided by PatientChase has been excellent

Practice Administrator, Otley

By using PatientChase, what would normally have taken half a day has just taken 10 minutes!

GP QOF Lead, North Wales

We use PatientChase and find it invaluable, it saves a lot of time and helps us organise our work effectively

Sue Careswell, Leckhampton Surgery

As a practice we have relied upon PatientChase to streamline our patient recall system for several years now. I consider this an essential tool

Karen Walsh, Chilcote Surgery

From Our Blog

See More Posts
21st Feb 2021

Covid searches in PatientChase – new updates

In line with modifications in vaccination criteria, please update PatientChase and re-import the searches from EMIS. These falls in line with the most recent government guidelines.

Read More
7th Feb 2021

Covid searches in PatientChase – Important enhancements

Following on from our recent blog outlining the use of PatientChase to manage Covid vaccinations, we’ve made some extremely useful enhancements to the information you will see in PatientChase’s Covid searches. These falls in line with the most recent government guidelines.

Read More
7th Jan 2021

New Feature - Using PatientChase to identify patients who have not yet had 1st or 2nd Covid vaccinations in line with the government’s priority groups

We have now deployed a suite of Covid searches which can be accessed in the PatientChase Search Builder. The data of eligible patients who have not yet had a 1st or 2nd vaccine is taken directly from EMIS and our searches are in line with the government’s priority groups of the most vulnerable. Now they are in PatientChase, it is very easy for you to cross reference lists, identify those who still need a 1st or 2nd vaccination and see who has or hasn’t an appointment booked for either vaccination.

Read More
16th Dec 2020

New Feature - Using PatientChase to target patients needing medication reviews!

We are delighted to announce that it is now possible to use PatientChase to target patients who are showing in EMIS as needing a review of their medications. This is a whole new suite of searches which can be selected within our Search Builder.

Read More
Dr. Raza Toosy

Dr. Raza Toosy

Raza is a current partner of a GP practice in Wallington, Surrey. He has had a passion for IT for all of his life and obtained an MScIT in Kingston University with Distinction in 2008 whilst still working as a GP. With his knowledge of both medicine and information technology his focus and vision is to create a line of business applications for GP surgeries and has been actively involved in the development of PatientChase and now PatientLeaf since 2005 using the .Net Framework. He's always wanted to improve the way clinicians access and view data to make their lives easier.

Dr. Raza Toosy

Richard Chmielowski

With qualifications in business and marketing and having previously held managerial roles in both primary and secondary care, Richard Chmielowski is co-founder of GPSS. Passionate about helping primary care staff manage their patients in the best way possible, Richard is involved in many of the customer facing aspects of delivering IT solutions.