The challenge

Some time ago, Sasha’s Primary Care Network (PCN) implemented risk stratification software to profile practice lists and identify patients most at risk of developing long-term conditions or other health issues. GP practices within the PCN have since made good progress within the diabetes care pathway, but have been unable to resource further preventative measures owing to conflicting priorities and pressures.

Sasha and other GPs within the network are frustrated that patients continue to develop preventable conditions or experience avoidable exacerbations of their condition, knowing this is directly affecting health outcomes and experience. It is also increasing the amount of clinical intervention required, impacting on GP time as well as the cost to the NHS.

The PCN approaches Agentis Healthcare to explore opportunities for responding to patients at greater risk of developing COPD, as well as managing patients who have already developed the condition.

Our solution

Agentis Healthcare offers a clinically led solution for managing this pathway end-to-end, which integrates seamlessly with the PCN’s existing risk stratification software and with practice patient records. For example, we can:

• Arrange for at-risk patients to be reviewed by the most appropriate professional, which might be a qualified pharmacist, nurse or, in acute cases, a doctor. Reviews would typically be undertaken online or over the phone – whichever is most appropriate for the patient – eliminating the need for home visits or for patients to visit clinics.
• Arrange medical tests and diagnostics as appropriate, such as referrals to local services for spirometry or pulmonary rehab.
• Develop personalised care plans based on the treatment or management needed.
• Train patients to support self-care and prevention, including instructions on how to upload spirometry and other results to track their progress.
• Provide patients with access to our Living With app, equipping and empowering them to manage their own condition.
• Give the patient immediate access, both digitally and via telephone, should they need any support or advice.
• Update patient records automatically throughout, providing practices with the ability to track and audit activity.

NB: this is an illustration of how we can support practices improve health outcomes, patient experience and practice capacity.