Long Term Reviews
From March 2022 BHWC patients who have long term conditions will have their annual reviews scheduled on their birth month. Whilst the practice is adopting this new system you may find that your reviews may be earlier or later than usual, so please bear with us during this transition. We do not think this will impact on your care as clearly those individuals who need changes to their management will be ongoing as usual.
Chronic health/ Long term conditions include: asthma, chronic obstructive pulmonary disease (COPD), hypothyroidism, diabetes, hypertension, atrial fibrillation, chronic kidney disease, and cardiovascular diseases (coronary heart disease or previous heart attacks, angina, heart failure, strokes, transient ischaemic attacks (TIAs) or mini-strokes, and peripheral vascular disease); rheumatoid arthritis and osteoporosis; people with severe mental illness (schizophrenia and bipolar disorder or other psychotic disorders) or people with learning disabilities. Some other conditions set up for regular recalls includes those apple with pre-diabetes and bariatric surgery.
Most conditions need a review once a year but some need more frequent reviews such as hypertension and diabetes which need a review every 6 months. Patients suffering from more severe forms of asthma, COPD, chronic kidney disease, or heart failure will need more frequent reviews. Furthermore anyone with a new diagnosis or treatment changes will need closer supervision and this will be decided by your clinician.
The aim is to make the reviews more effective through coordinating the recall system, using technology through the use of questionnaires, and having blood tests and health checks performed by the healthcare assistant (HCA) team prior to a review by the clinical team responsible for each condition.
All the respiratory conditions (asthma and COPD) are being managed by the Pharmacy team with input from the Practice Nursing team as needed.
Diabetic reviews are being performed by the HCAs who will do a health check, foot check, blood and urine tests with the full review being completed by the Practice Nursing team. If your diabetes is under appropriate control an interim review at 6 months with a blood test is required only.
All cardiovascular reviews including hypertension and atrial fibrillation are being managed by the Pharmacy team with support from the HCAs who will perform your health check and blood tests.
People with severe mental illness or learning disabilities will have a coordinated health check and review from the HCA, Practice Nursing and Pharmacy teams as appropriate. If you are over 40 years old and don’t have any pre-existing conditions it is recommended you have an annual health check with blood tests with the HCA prior to your review. Some individuals may need extra blood tests to monitor their medication.
People with rheumatoid arthritis or heart failure or osteoporosis are being managed by the Clinical team.
Patients who have combinations of long term conditions will be managed by the most appropriate teams as outlined above. Diabetic and cardiovascular reviews overlap so these will be managed together.
Many long term conditions can be effectively managed by the use of questionnaires, health checks with the HCA team if required. This means that a review can be performed over the phone or remotely instead of needing a face-to-face appointment which may be more convenient for you but there will be a choice. In some circumstances if your conditions are well-controlled you may be informed by text message or email only.
We are aware that some patients will need information or reviews performed in ways suitable for their individual needs. Housebound patients are being managed by our HCA visiting team.
To assist us with your reviews please keep your contact details up to date (phone numbers, email address and postal address) which can be updated on your online account or by calling reception on 01273 772020.