Population health:
We have prioritised our investment in social prescribing through ARRS. Their role has a strong population health focus, helping to address the wider determinants of health and wellbeing for our local population, including helping us address vaccine hesitancy in vulnerable groups. The social prescribers will run a different PCN based population health projects every 4 months, with plans to focus on:
- Rising Risk patients (particularly those with metabolic/mental health) using WSIC dashboard to assist in case finding
- Support Asylum seekers through social prescription
- Health and wellbeing pop ups at St Matthew's church
To ensure we are meeting the needs of the whole population, we are discussing employing a 4th social prescriber as a children and young adults social prescriber, given we are seeing a rise in children's mental health as a consequence of the pandemic. We plan to further support our social prescribers and population health management by employing health and wellbeing practitioners through ARRS, who will use a data driven approach to case find patients likely to benefit from coaching.
We are using population health data on frailty and non-elective activity to review and map out our ICT staff allocation and ensure there is equity amongst practices and resources go to area of need. This also includes an ambition to make DN teams PCN facing. Our PCN Lead clinical integrator Zaby Begum is support this work.
As a future project/ambition, our Associate Director Dr Anna Cantlay is in discussions about a PCN Frailty MDT with geriatricians that would happen weekly, with practices encouraged to use a systematic data-driven case finding approach to identify patient's of high need due to frailty and complex comorbidity.
We plan to use PCN development monies towards the employment of a BI/data analyst who can analyse, digest and present our local population health data as a regular PCN agenda item. This would include PCN KPIs for key Extended Serves/OOH for long term conditions such as SMI/Diabetes, as well as PCN DES performance.
Diabetes
To improve diabetic care for Brompton PCN, we will run Diabetes Virtual Group Consultations from September 21-March 22. We plan to engage 295 local and high risk patients in the consultations which have compelling evidence at improving diabetic outcomes. Once our Health and Wellbeing coaches are in post, we hope to use a data-driven approach to focus their role, with a likely focus on diabetes care. Our PCN lead integrator Zaby Begum is also leading on integrating the Diabetes MDT at PCN level.
Dear Brompton PCN,
We are working on finalising the pathway to delivery PCN Virtual Group Consultations as part of the Level 1 Diabetes ES (Agenda item PCN meeting 22/7). VGCs equate to 40% of the Level 1 KPIs. In order to meet KPI requirements, we need to engage 12.5% of our T2DM register in VGCs.
Action - Case finding
To prepare for the delivery of VGC in September, practices are asked to begin case finding and searching for appropriate patients to engage in VGC. The NWL guidance suggests high risk patients should be prioritised, but any T2DM will qualify. High risk patients include the following groups, and Matt Smith has created a S1 search to facilitate the process (see attachments for screenshot).
- BMI >30
- Cardiovascular disease
- High risk Feet
- egfr <45 or proteinuria
- BAME
- Hba1c >58 in <70 year old, >65 in >70 year old
Practices will need to find at least 12.5% of their T2DM to engage in consultations. A reserve list is also advised to account for DNAs. Please see numbers below:
We suggest patients be contacted via MJOG, email or call to assess their willingness to participate. Attached you will find an MJOG draft text and invite letter that you may wish to use.
Due to the need to mobilise by September to achieve the KPI, we ask that practices have their lists ready by the 30th July 2021. Please ensure all the on your list have an up to date email
Please don't hesitate to get in touch if you have any questions.
