TABLE OF CONTENTS
- Introduction
- Accessing Continuity of Care Data
- Navigating Continuity of Care Data
- Additional Information
Introduction
To ensure continuity of care, Ardens Manager enables you to identify patients who would benefit from tailored support by categorising them into risk groups. This support article will guide you through using the dashboard to identify these patients and promote more consistent, person-centered care in your practice.
Accessing Continuity of Care Data
Select the Services icon and click on Appointments.
To view your data, click on the Continuity of Care tab.
Navigating Continuity of Care Data
Using the Data
Monitor how many patients require Continuity of Care within the Register section.
Important! The patient must be coded in your clinical system to appear on this register. There are two different codes which can be used: 'Providing continuity of care (423215004)' and 'Continuity of care management (423779001)' |
Monitor how many patients are in each risk group using the Personalised Care section
Ensure your register is up to date by reviewing the Data Quality reports.
To review these patients, click on View.
Click on the Patients tab to identify the patient details to review.
Click the copy icon next to the patient's name, then paste it into your clinical system to review the record and take appropriate action.
Interpreting the data
Use the Demographics tab to gain insights into the dynamics of your patients across various groups. Analysing patient dynamics offers numerous benefits, such as enabling tailored interventions, identifying health inequalities, and supporting workforce planning. For example:
- Tailoring interventions
- Older patients in the Red group may benefit from home visits or frailty reviews.
- Patients with language barriers may need translated materials or interpreter support.
- Identifying health inequalities
- Are certain groups over-represented or are patients from more deprived areas more likely to need continuity?
- These insights can guide targeted outreach or service redesign to address disparities.
- Supporting workforce planning
- Help allocate the right staff to support patients in various groups, for example:
- Care-Co-ordinators can support socially complex patients
- Clinical Pharmacists can support polypharmacy in older adults
- Mental Health Practitioners can support younger patients with complex needs
- Help allocate the right staff to support patients in various groups, for example:
- Informing PCN level planning
- Population health management strategies at group level
- Planning enhances services (e.g. anticipatory care, personalised care planning)
- Monitoring change over time to track the impact of interventions or changes in service delivery.
To analyse your demographic data, click View.
Click on the Demographics tab.
Additional Information
The Continuity of Care resources are built upon the Foundry Healthcare operational model based around patient segmentation on the basis of need. This was cited in the Fuller Stocktake Report to improve access and keep patients out of hospital by streaming patients using systematic triage and clinical judgement. If you would like to learn more about how to implement the Foundry Healthcare Operational Model, then please visit the Foundry Healthcare website for more information and support from their team.
The following RAG statuses and codes are used:
Colour | Code | Continuity of Care |
Green | General health good (135815002) | Less important |
Amber | Chronic long term disease management required (416239002) | Important |
Red | Chronic long term disease management required: Complex needs (416239002) | Paramount |
A suite of Ardens resources is available for both SystmOne and EMIS Web, including data entry templates, reports, patient alerts, and protocols.
To learn more about these resources, see the support articles for SystmOne Practices and EMIS Practices.
If you require any further assistance on the process above, please contact the Ardens Manager Support Team on: support-manager@ardens.org.uk