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Drawn from coo-ordinated care NIS. Care planning encounter to encompass: Health review Functional capacity based on the response Falls risk – consider referral to falls clinic Cognition Mood – Consider psychology Mental Capacity Polypharmacy Anticipatory Care Plan.
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Drawn from coo-ordinated care NIS. Care planning encounter to encompass: • Health review • Functional capacity based on the response Falls risk – consider referral to falls clinic • Cognition • Mood– Consider psychology • Mental Capacity • Polypharmacy • Anticipatory Care Plan Process flow for Co-ordinated Care NIS Admin (30mins) Admin GP (incorporated in 40 mins) Health Care Assistant (45 mins) Admin (15 mins) • Consent for data sharing • Data request to social careand mental health • Invitation for health review • Develop care plan – including details of care navigator • Review – completion of template and questionnaire • Enter Reuben results via CC CEG and include walking speed • Enter information from social care and mental health • Care and and investigation for disease specific as appropriate GP (20 mins) • Review 3 x per year • Discussion at CHT meeting if on caseload. • Data uploaded – including CMC ? • Contact number care navigator – contacts patient once a quarter or sooner • Review of medical records • Results of questionnaire • MDT meeting within practice GP (40 mins) GP (30 mins)
