Copyright © INPS Ltd 2014

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Vision 3

Unplanned Admissions - Personalised Care Plan

Manager

Outcomes Manager

Copyright Notice

© 2014 INPS

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INPS Ltd.

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Website: www.inps.co.uk

Contents

PERSONALISED CARE PLAN MANAGER 5

What this User Guide Covers 5

The Two Types of Unplanned Admission Templates in Vision 5

How to Access the Personalised Care Plan Manager Template 6 Accessing the Template via the Personalised Care Plan Register 6 Accessing the Personalised Care Plan from Clinical Templates in Consultation Manager

8 Accessing the Personalised Care Manager Template from the Alert Popup Window 9

Managing your patients using the Personalised Care Plan Manager Template11 Care Plan Administration Tab 12 Past Medical History Tab 13 Home Visit Manager Tab 14 Anticipatory Care Tab 14 Blood Results Tab 15 Hospital Discharge Manager Tab 17 Admissions Risk Assessment Tab 18

Applying the QAdmission Risk Calculator to an Individual Patient 18 Medication Management Tab 21

iii

Care Plan Review Tab 22

INDEX 23

5

Personalised Care Plan Manager

What this User Guide Covers This user guide explains how to use the Personalised Care Plan Manager Template to

manage and monitor your patients. It covers the following topics:

An Overview of the two types of Personalised Care Manager Templates -

See The Two Types of Unplanned Admission Templates in Vision (page 5).

How to Access the Personalised Care Manager Template - See How to

Access the Personalised Care Plan Manager Template (page 6).

Managing your patients using the Personalised Care Manager Template -

See Managing your patients using the Personalised Care Plan Manager Template (page 11).

The Two Types of Unplanned Admission Templates in Vision There are two Unplanned Admission Templates in Vision that will help standardise

data recording for improved reporting. Below explains the two template options

available:

Personalised Care Plan Manager - The Personalised Care Plan

Manager Template should be completed for those patients already on the

Unplanned Admissions Risk Register. The template contains all the

relevant information for proactive case management and personalised

care planning. It should be used to support and monitor your patients.

See How to Access the Personalised Care Plan Manager Template (page 6).

Admissions Risk Stratification and Register Manager

(Personalised Care Plan Manager Register) - This is a short

template that is used to add the patient onto the Unplanned Admissions

Risk Register and record their offer/acceptance details and a named GP.

It is also where you can print the Care Plan invitation. For more

information on adding a patient to the Unplanned Admissions Register

refer to the Unplanned Admissions Outcomes Manager Getting Started

User Guide.

6

How to Access the Personalised Care Plan Manager Template There are three ways to access the Personalised Care Plan Manager Template:

Practice Reports - Access the Personalised Care Plan from Vision+

Reports. See Accessing the Template via the Personalised Care Plan Register (page 6).

Clinical Templates - Select the Personalised Care Plan from Clinical

Templates in Consultation Manager. See Accessing the Personalised Care

Plan from Clinical Templates in Consultation Manager (page 8).

Alert Popup window - Use the Alert Popup window to invoke the

Personalised Care Plan Manager Template. See Accessing the

Personalised Care Manager Template from the Alert Popup Window (page

9).

Accessing the Template via the Personalised Care Plan Register

To access the Personalised Care Plan Manager for the patients on the at risk register

from Vision+ Reports:

1. Log into Vision, right click on the Vision+ icon in the Windows Notification

area and select Practice Reports.

Other - Practice Reports

2. Select the Enhanced Services icon and choose Personalised Care Plan

Manager.

Enhanced Services - Personalised Care Plan Manager

7

3. A suite of reports are listed. Initially, you will want to find those patients who

have not had a Personalised Care Plan created before the September deadline.

However, this will change throughout the year as you target different cohorts.

Personalised Care Plan Manager Reports

4. Highlight the line Q1 Reporting Care Plan Agreement NOT in Place for

Patient.

Patients on the Personalised Care Register with no Care Plan created

5. To view patient names double click on the cohort line or choose the expand

icon.

6. Highlight the patient and choose Show Template.

Reports - Show Template

Training Tip - Use the toolbar at the top of the screen to Print,

Export or work with the patient list. Refer to the Vision+ on-screen help for more information on working with patient lists.

8

7. The Personalised Care Plan Manager screen is displayed.

Personalised Care Plan Manager

For information on recording data on the Personalised Care Plan Manager Template -

See Managing your patients using the Personalised Care Plan Manager Template

(page 11).

Accessing the Personalised Care Plan from Clinical Templates in Consultation Manager

1. In Consultation Manager, select a patient.

2. From the Windows Notification Area, right click on the Vision+ icon.

3. Select Clinical Templates or click the Vision+icon off the floating

toolbar and select Clinical Templates.

Floating Toolbar

Clinical Templates

9

4. Select Personalised Care Plan Manager.

Personalised Care Plan Manager

For information on recording data to the Personalised Care Plan Manager Template -

See Managing your patients using the Personalised Care Plan Manager Template

(page 11).

Accessing the Personalised Care Manager Template from the Alert Popup Window

1. Alternatively, to view missing or due data pertaining to Unplanned Admissions

use the Alert popup window. Click the Show ES Indicators icon to access the

Alert popup from the Vision+ floating toolbar.

Note - By default QOF alerts appear when you select a patient in

Consultation Manager, to combine both QOF and non QOF alerts, refer

to Vision+ Settings - Combine Triggers option.

Vision+ - ES Indicators (Enhanced Services) icon

2. The Alert popup window displays the Personalised Care Plan Manager heading

and is expanded to show missing or due data. This is particularly helpful when

monitoring home visits and discharge summaries.

10

Training Tip - Remember patients must be reviewed within 3 days

of receiving a discharge notification for Accident and Emergency and

non-elective admissions. An alert also appears if a home visit is

planned but not completed.

3. To launch the Personalised Care Plan Template either:

Right click on Personalised Care Plan Manager and select Show

Template

Highlight Personalised Care Plan Manager and click the Template

icon on the toolbar, or

Double click on one of the expanded lines below the Personalised Care

Plan Manager heading

Key Points

If a care plan agreement is not completed within three months, the alert will warn if a review is due in one or two weeks

If a care plan agreement is more than three months ago, Vision+ will

check for a subsequent care plan review and the alert will warn if none

present

If a care plan agreement and subsequent review has been done, Vision+

will check that the most recent review was within three months and will

alert if not, or prompt for a review to be scheduled in one or two weeks if

the review date is imminent

11

Managing your patients using the Personalised Care Plan Manager Template Below is an overview of each tab within the Personalised Care Plan Manager

screen. It is important to note that when using the Template the following options are

available:

Freetext Guidance

Where a Read code is limited and does not adequately cover the DES requirement

some guidance text will be provided in the template advising that you must choose

from a drop down menu in the Comments box.

Freetext Guidance

Important Information

A red exclamation mark or asterisk displays on the template if a Read code is

required in order to receive your DES payment or if you need to report on this

information.

Important Information

12

Adding Data

To add a Read code to the Personalised Care Plan Manager Template, click the

Codeset icon at the end of the line. For more information on how to add date

refer to the Vision+ on-screen help.

Viewing Data

To view historical data click the red Previous Entries icon. A blue Previous

entry icon indicates that the patient does not have any previous records.

Save and Close

All entries made to the screen should be saved by choosing the Save and Close icon.

If you do not save and close your data will be lost.

Save and Close

Care Plan Administration Tab

The Care Plan Administration tab contains essential information required for the DES

which must be completed. It includes patient information such as:

Contact and Carer details

Details of the patient's named accountable GP

Confirmation/details of consent given for data sharing

Capacity Assessment details

Care Plan Administration

13

Key Points:

The following Key Points should be noted:

Personal Care Plan Offered and Add to Personalised Care Plan

Register - Data can only be recorded on this screen after you have

recorded Personal Care Plan Offered and placed the patient on the

Admission Register by selecting Add to Personalised Care Plan

Register. Until then the boxes are greyed out. For more information on

adding the patient to the Unplanned Admissions register, refer to the Unplanned Admissions Outcome Manager Getting Started User Guide.

Capacity Assessment - The Read codes for a patient's capacity is

limited to 9NDL - Lacks Capacity Consent MCA 2005 and Read code

28F - Mentally Alert, it is therefore important that you also choose the

freetext comments from the dropdown list in order to record a more appropriate explanation.

Consent to Involve Carer - The Read code 9q - Consent Status does

not stipulate what consent, so you must choose from the drop down menu in the Comments box.

Telephone numbers of other professionals involved in care -

Enter name and contact details in the freetext comment box alongside

the appropriate contact information. This information is not linked to the contact details in Registration.

Past Medical History Tab

The Past Medical History tab is helpful for clinicians when completing the Care Plan as

it displays the patient's latest diagnosis categorised by body system. It saves you

from leaving the template and looking in the patient's journal for relevant clinical

information. To view previous entries click the icon.

Past Medical History

Note - Data can also be entered on the template by using the

Codeset icon at the end of the line.

14

Home Visit Manager Tab

The Home Visit Manager tab contains all the information required to capture the

process flow around home visits, ensuring that patients are seen appropriately, as per

the DES requirements. It details the home visit request, plan and outcome.

Home Visit

Key Points:

The following Key Points should be noted:

In the section Home Visit Required, select the type of visit planned and choose the urgency from the drop down Comments box

If you complete the Home Visit Planned section an alert is

automatically triggered prompting you to visit the patient.

Outcome of Visit - This section is essential for reporting purposes as

you need to monitor all admission codes. The admission information is

also taken into account when applying the QAdmission calculator.

Previous Encounters/Outcomes - This displays previous home visit encounters and their outcome.

Anticipatory Care Tab

The Anticipatory care tab encompasses:

Palliative Care Register information

Palliative Care Review and Planning

End of Life Care Pathway information

Note - The End of Life Care Register Status uses a QOF Palliative Care code so this may affect your QOF register.

15

Anticipatory Care

Blood Results Tab

The Blood Results tab is pre-populated with the patient's latest blood results and is

categorised to help clinicians manage the patient's care. To view previous results click

the Previous entries icon at the end of the relevant line. If you do not use

electronic test requesting you can also record test requests on this tab by selecting

the Blood Test Requested option.

Note - A graph also shows historical results.

16

Blood Results

17

Hospital Discharge Manager Tab

The Hospital Discharge Manager tab is where you can view and record details of

discharge notifications for Accident and Emergency and Non-Elective Admissions.

Hospital Discharge Manager

Key Points

The DES requires you to monitor the date a patient was discharged from

hospital and the date the practice received the discharge summary. This

information should be recorded under the section Post Discharge Practice Actions.

Training Tip - The template uses Read code 93A - Discharge

Summary when the discharge summary is received. Some scanning

operators use the Read code 93A - Discharge Summary to record the

date the patient was discharged from hospital so you may need to review your scanning protocol.

18

You are also required to do a post discharge patient review within 3 days

of receipt of the Discharge Summary (excluding weekends). To record

this information you must complete the section All Patients

Discharged from Hospital Require a Post Discharge Review. The Alert popup window will also prompt for this information if not completed.

Post Discharge Review

You are also required to do a full patent review, which must be completed on the Care Plan Review tab. See Care Plan Review Tab (page 22).

Admissions Risk Assessment Tab

The Admissions Risk Assessment tab displays the patient's QAdmissions Risk score

history. The QAdmission score can either be run on a group of patients or on an

individual patient. For more information on running the QAdmission Risk

Stratification tool on a group of patients - See the Unplanned Admissions Outcomes

Manager Getting Started User Guide. To run the QAdmission on an individual patient

- See Applying the QAdmission Risk Calculator to an Individual Patient (page 18).

Admissions Risk Management

Applying the QAdmission Risk Calculator to an Individual Patient

You can run the QAdmission Risk Score on an individual patient at any time. There are

two ways to do this:

Personalised Care Plan Manager Template

1. From the Personalised Care Plan Template, select the Admissions Risk

Assessment tab.

2. Click the QAdmissions Calculator icon.

19

| 1`

QAdmissions Calculator - Personalised Care Plan Manager Template

3. The QAdmissions calculator screen is displayed. You can view existing

patient data or add new data to this screen. For more information on how to

use Vision+ Calculators refer to the on-screen help.

QAdmissions Calculator

20

4. To run the QAdmission calculator click Calculate. The QAdmissions Read code

38Gt0 - QAdmission risk emergency hospital admission next 12

months is shown along with the patient's score. To record both the Read code

and the score in the patient's record, click OK.

QAdmissions Calculator - Read code and Score

Vision+ Calculators

1. Select the patient in Consultation Manager.

2. Click the Vision+ icon on the floating toolbar.

Vision+ icon - Floating toolbar

21

3. Select Calculators - Other and choose the QAdmissions calculator.

QAdmissions Calculator

Medication Management Tab

The Medicine Management tab shows the patient's current active repeat medication

and their medication review details. You can also view and record the Allergy Read

code 14L - H/O: drug allergy. However, the drug does not display on the screen or

in the printed version of the Personalised Care Plan.

Medications Management

Note - If you add a medication review via this tab it is added as a

History entry and not on the Medication Review Structured Data Area (SDA).

22

Care Plan Review Tab

You must complete as much information as possible on the Care Plan Review tab as

this constitutes the patient's full Personalised Care Plan and is an essential

requirement of the DES.

Care Plan Review

Key Points

The section Agreement of Personal Care Plan must be completed by

recording the Read code 8CSB - Admission Avoidance Care Plan Agreed.

You must review the patient's care plan every 3 months and within 1

month of any emergency admission/attendance. Completing the section

Review of Personal Care Plan will Read code 83MG3 - Review of admission avoidance care plan.

Select the link Click HERE for the patient personalised care plan, to print

the patient's full care plan. This opens a word document which is

pre-populated with the patient's details. This document should be printed

and signed by the clinician and patient. For audit purposes it is recommended that you scan the document into the patient's record.

23

Index

A

Accessing the Personalised Care Manager Template from the Alert Popup Window • 6, 9

Accessing the Personalised Care Plan from Clinical Templates in Consultation Manager • 6, 9

Accessing the Template via the Personalised Care Plan Register • 6

Admissions Risk Assessment Tab • 19 Anticipatory Care Tab • 15 Applying the QAdmission Risk Calculator to an Individual

Patient • 19, 20

B

Blood Results Tab • 16

C

Care Plan Administration Tab • 12 Care Plan Review Tab • 19, 23 Copyright Notice • ii

H

Home Visit Manager Tab • 15 Hospital Discharge Manager Tab • 18 How to Access the Personalised Care Plan Manager

Template • 5, 6

M

Managing your patients using the Personalised Care Plan Manager Template • 5, 9, 11

Medication Management Tab • 22

P

Past Medical History Tab • 14 Personalised Care Plan Manager • 5

T

The Two Types of Unplanned Admission Templates in Vision • 5

W

What this User Guide Covers • 5