Keep well Tracking Tool

Practice Side User Manual

Version 2

Contents

  1. About the Tracking Tool
  2. The Main Menu
  3. Searching for a Patient
  4. Logging an Invite
  5. Editing an Invite
  6. Appointing a Patient
  7. Maintaining Appointments
  8. Recording Appointment Outcomes
  9. Lists
  10. Invitations List
  11. Referrals Made
  12. Patient Summary Page
  13. Reports
  14. Registered List
  15. Referred Back

1.About the Tracking Tool

The key aims of the tracking tool are:

  1. Record attempts made to bring patients into the practice;
  2. Record what invitations resulted in appointments;
  3. Record attendance of the appointment;
  4. Record outcomes of the appointment (referrals/signposts/advice);
  5. Follow up on progress with services.

The Tracking Tool is NOT an appointment or referral system – it should work in addition to existing clinical systems and processes by recording the fact an event occurred.

For the project to be evaluated thoroughly at both local and national level it is important that information is recorded accurately and in a timely fashion on the Tracking Tool

2.Main Menu

The main menu is the first page a user will see when logging in.

It runs down the left-hand side of the screen, and has two main sections: Find a Patient, and Lists.

To expand either of these sections, click on the appropriate heading.

Search for Patients

This page allows you to search the database for a patient using Forename, Surname, DOB, or CHI number. This is where you will register new patients also.

Clinic List

This I a list of all appointment logged in the Tracking Tool on a given date.

It also lets you view “Not Actioned” appointments i.e. Appointments sitting as “not known” when the appointment date has passed.

Invitations List

This is a register of all invitations that have been logged for your patients.

It allows you to filter out by Invitation Type, e.g. Letter, Telephone, Opportunistic.

Referrals Made

This is a register of all Full Referrals that have been logged as a result of appointments within your practice.

Reports

This is a list of local and national reports which pull data from the live system.

Registered

This screen pulls all patients aged 45-64 at your practice from the database.

From here you can log invites and get a brief summary for each patient.

This is also where you have the option to “Exclude” someone if they have moved away for example.

Registered / New Keep well Patients

All practices must search for new Keep well patients i.e. those turning 45 in the lifetime of the project. This is a GPASS search which lets practices identify “new” Keep well patients. Search is called “2010 Catch Up Search” – this sits in GPASS and pulls out eligible Keep well patients who haven’t been given the Keep well “tag” (Read Code 6C0..)

Referred Back

This screen shows patients which have been passed back to the practice following a referral onto a secondary care service through Keep well.

Searching for a Patient

To search for a patient you will need the CHI number or Surname and DOB.

When you click “Search” the search will run against the database and the results will be displayed as below.

If no results are found, the system will let you run the same search against the SCI Store and the results will then be brought in from CHI.

On the results grid there are three links:

Patient Summary- This gives the practice a patient-centric view of all the Keep well referrals and signposts accepted by the patient.

Invitations - This is a practice-specific view of all the attempts made to contact the patient and bring them in to the practice for an appointment.

Edit Patient- This screen is the Patient Details page, and holds demography, contact details and various other pieces of social information relating to the patient.

3.Logging an Invite

When logging an invite the user must:

a)Select a date (defaults to today’s date);

b)Select an invitation method;

c)Select any further information about the invite;

d)Select the outcome of the invite.

Additional information may be asked for depending on the Invitation Method selected.

If “Letter” the user will also need:

a)Letter Header (what logo was on the letter)

b)Letter Version (a practice specific version number)

The Further Info field will relate to the type of letter sent.

If selecting a “Telephone call”, the system will also prompt for:

a)The person who made the call (defaults to the logged-on user)

b)The time of the call (it is important to capture this, as it will be reported on)

c)Any “Further Info”, for example if you spoke to the patient.

The control used to select the time lets you quickly pick the time without having to use the keyboard.

If there is no immediate appointment to be recorded as a result of the invite click “Insert” to save the information.

The “Invite Outcome” is limited depending on what method is being used. For example, on sending a “Please Contact” letter out the only Outcome will be “No Response” until the patient replies. Similarly if leaving an answer phone message/message with family.

If you have sent an “Appointment” letter you will be prompted to record the details of the appointment you issued. (Section 6)

4.Editing an Invite

Once an Invitation has been saved, it will be visible in the gridview at the bottom of the screen.

To edit details of the Invite click “Edit” on the left hand side.

Instances where you may wish to edit an Invite include:

a)If you have sent a letter/telephoned asking the patient to contact the practice for an appointment and the patient has come forward to make an appointment you would set the “Outcome” of the invite to “Patient Returned Contact – Appointed”.

Similarly if they returned contact to the practice declining an appointment, you would set the status to “Patient Returned Contact – Refused”, or “Patient Returned Contact –Pt will recontact”

b)If there was a keying error you would make the corrections here also.

Once the amendments have been made click “Update” to save changes.

5.Appointing a Patient

If the “Outcome” of the invite is “Appointed” (or in the case of the patient returning contact to the practice and being appointed: “Patient Returned Contact – Appointed”) then you will be prompted to enter a new appointment.

Click “Add New” to record the new appointment details.

Enter the date and time of the appointment.

For “Type” you need to chose “Baseline”, or “Follow-up”.

Baseline

This would be the initial appointment(s) taken to complete the Keep well template. It could be one “full” appointment, or multiple “part” appointments depending on how your practice has chosen to schedule appointments.

Follow-up

Follow-up should be used to log appointments where the patient has had to come back in following completion of the template for clinical follow-up e.g. positive spirometry, cholesterol, diabetes, fasting glucose.

This is really to monitor the amount of work in practice generated by Keep Well.

The Outcome and Completion will default to “Not Known” at this time.

When happy, click “Confirm” and it will save the Invitation information, and the Appointment information.

To edit detailsat any time you can “Edit” the appropriate invite and then click “Edit” next to the appointment in the top right hand side of the screen.

Any appointment entered here will be visible in the “Clinic List” for that date, available from the main menu.

If “Part” appointments are being used and a patient is given the return date it should be logged against the same invitation, as below.

If a patient DNA’s the initial appointment, a new invitation should be logged to show the process you would go through to invite them back in – for example a telephone call being made.

In the example above, a telephone call was made on the 7th Dec and an appointment was booked for 17th.

The patient DNAd that appointment however, so a telephone call was made on the 18th to invite them back in, and they were re-appointed them for the 25th.

Reminders

Reminders are used to remind a patient about a specific appointment.

They can be telephone calls, confirmation letters, or even opportunistic.

An example of using a reminder could be:

Telephone Call made on the 7th – and appointment booked for the 14th.

A letter is also sent out on the same day with details of the booked appointment to confirm the date and time.

This would be logged against the appointment by clicking “Remind”

This type of letter should NOT be logged as a new Invitation Letter, with “Appt Given”, as this would look like the patient had two invitations when they hadn’t – they have had one Invitation (the telephone call), and one confirmation letter.

ALL REMINDERS MUST BE RECORDED

Maintaining Appointments

To record whether a patient attended or not you can either go through searching for the patient then the invites screen to “Edit” the appropriate invite and appointment, or use the “Clinic List” screen on the main menu.

This screen lists all appointments on a given date.

To record attendance, click “Edit” on the right hand side and pick the appropriate outcome (Attended, DNA, and Cancelled) and the appointment completion (Part, or Full).

Click “Update” to save the changes.

If the outcome has been marked as “Attended” a link will appear on the right allowing the user to record any outcomes of the appointment (referrals/signposts).

6.Recording Appointment Outcomes

By clicking on the “Record Outcomes” link you are taken to the screen giving a tabbed list of all various areas in the Keep well Project.

The two key items being recorded here are Signposts and Referrals.

Signposts

A signpost is recorded at the top of the screen, where for example the Smoking Advisors Contact Information is passed to the patient, and the patient can make their own engagement with the service.

The service would be able to see the fact you gave the information out and this will allow the project to report on the effectiveness of signposting.

When signposting the date the signpostis given should be recorded (default to today’s date) and the person at the practice who issued the signpost (defaults to logged-in user).

Full Referrals

This would be where a full referral was made to the service following the services own referral protocol as detailed in the Keep well Directory

Please note that paper referral forms must also be sent in addition to the referral being tracked here.

The Tracking Tool allows the user to select what service the referral was sent to, and what method was used to refer.

Health Counsellors

The health counsellor is the gateway to weight management services (other than the Glasgow Weight Management Service), Healthy Eating Services, and Physical Activity Services.

The full referral options here allow the user to specify the reason for referral.

If it is for Physical Activity and the patient is “High Risk”, an exercise tolerance test must be completed at a hospital.This should be recorded on the tool.

Once all outcomes have been recorded click “Insert All” to save all the details and you will be returned to the main menu.

7.Lists
a)Invitations List

The Invitations List can be reached from the Main Menu.

It provides a record of all attempts made to contact patients by the practice.

At the top there is a dropdown to filter the list by.

It includes:

i)All Attempted Invites

This is all attempts/invitations logged against all patients

ii)Outstanding Invites

This looks at the most recent invite for each patient, and checks if it is currently sitting as “No Response”. If it is, it will be displayed in the list. These patients may then be chased up.

There is also the option to filter by how long ago the invite was sent:

Longer than: 1 Week, 2 Weeks, 4 Weeks, 3 Months, 6 Months, 12 Months.

Additionally, there is an option to show only certain Invite Methods, e.g. Letter, Telephone Call etc.

This would allow the user to filter by letters older than 4 weeks for example.

b)Referrals Made

This screen shows all the full referrals the practice has sent on to services.

The dropdown at the top allows the user to filter out by where the referral was sent, and the dropdown below lets the user filter out by what status the referral is currently at.

The default status for a referral is “Not set”.

When a service picks up the referral and starts to contact the patient, they set the status to “In System”.

When the referral is closed, the service would then pick a closure date and an appropriate status:

Completed Success, Completed Partial Success, Completed Failure, Did Not Complete and DNA.

8.Patient Summary Page

The patient summary page gives a patient focused view of what has been recorded on the tracking tool against the patient’s record.

9.Reports

This section will contain several reports giving a practice-specific picture of what data has been entered into the system.

Some reports contain anonymised data for other practices to give the user a feel for what is happening across the city in other practices.

  1. Registered List

This screen gives a list of all patients within the application who are registered in the users practice and within the Keep well age range.

It shows how many invitations each patient has had, if the patient has ever “Refused” an invitation, if the patient has ever been appointed and if they have ever attended an appointment. At the end of the grid, it shows the most recent appointment date (if any), and what the outcome was.

By clicking on the CHI number the user is taken to the “Invitations” page.

By clicking on the Summary link the user is taken to the “Summary” page.

The “Exclude” option allows the user to go in and Exclude the patient from appearing in the list in future.

An example of this could be the patient has moved away.

Click on the “Exclude” link, and enter a reason, as below.

  1. Referred Back

This screen shows a list of patients who have been referred back to the practice from a service, and why.