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Effective Care Pathways for Acute and Chronic Conditions: Targeting At-Risk Patients

Feedback from practice visits in January 2012 focusing on the rapid response of acute pathways and variable outcomes. Strategies to target at-risk patients before winter for medication/SMP review and acute pathway updates. Enhance annual reviews with a focus on outcomes and actions, provide practical support during SMP/Annual reviews, and engage link nurses for practices with high prevalence/admissions. Implement proactive practice follow-up for COPD discharge and liaise with medical/nursing teams for selected patients in the hospital.

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Effective Care Pathways for Acute and Chronic Conditions: Targeting At-Risk Patients

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  1. Feedback from practice visitsJan 2012 RM Acute pathway- rapid response- variable- does it actually work Targeting at-risk patients before winter- review meds/SMP/acute pathway Chronic- update annual review proforma focus on outcomes and actions SMP/Annual review practical support- sp nurse to visit on clinic day- esp recurrent admitters

  2. RM2 • Develop link nurses- esp with practices with high prevalence/admissions • Proactive routine practice follow-up 1 week after COPD discharge • ?visit patients in hospital to liase with medical/nursing teams in selected patients

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