Outcomes Manager – Unplanned Admissions DES

1. Outcomes Manager – Unplanned Admissions DES

2. Unplanned Admissions DES Personalised Care Plan Manager • A dynamic template based on the example within the DES Documentation. • Backed up by relevant patient alerts and practice reports that enable the personalised care plan to remain up to date and relevant. Risk Stratification and Register Manager • 2 Versions • Qadmissions Risk Stratification • Non-Validated Risk Stratification • Both contain a 2% Monitor

3. “A Record within a Record.” More than an electronic version of the DES template. Personalised Care Plan Manager

4. Clinical Information presented in a Clinically Relevant way. Personalised Care Plan Manager

5. Simple data entry to be able to track processes. Personalised Care Plan Manager

6. Useful clinical alerts to help identify potential increased risk of admission when in a patient record. Personalised Care Plan Manager

7. Clear Care Plan Summary Tab for Quick Reference Action plan documentation Personalised Care Plan Manager

8. Personalised Care Plan Manager • Electronic version populates the fields within a printable version for patient.

9. Personalised Care Plan Manager • Practice Reports allow efficient management of patients on the register • Excel files can be generated to build up evidence in support of payment claims. • Outstanding tasks to fulfil DES targets is listed.

10. Personalised Care Manager – Additional Functionality • Consent/Capacity prompt and check • Anticipatory Care – thorough documentation and planning • Home Visit Logging and alerts • Adverse drug reaction monitoring and alerts • Blood results trend and absolute value alerts • Centralised Dashboard Reporting – adaptable to local needs.

11. Risk Stratification and Register Manager- Non-validated Categorisation - Number of Admissions in Last Year • CVD • CVA • Heart failure • Diabetes • AF • COPD • Asthma • Palliative Care • CKD • Dementia • Epilepsy • Learning Difficulties • PVD • Smoker • On Warfarin • On NSAIDs • Alcohol > 40 Units/Week • Obesity • On Mental Health Register • Cancer Diagnosis Risk Factors: Age: 90+ 80-89: 70-79: 60-69 50-59 <50: Risk Factor Count

12. Risk Stratification and Register Manager • Allows practice to make decisions based on categorised data • No probability of admission risk is reported • Cannot demonstrate change in risk

13. Risk Stratification and Register Manager • QadmissionsVersion: • Probability reported. • High level of granularity in the stratification. • Allows practice to demonstrate improvement in overall risk. • Stratifies register itself to enable high risk patients to be managed first.

14. Both Versions: 2% Monitor Run weekly, this can help practices stay on top of the workload, with patients easily being added/removed from the register. Risk Stratification and Register Manager