Personalised annual reviews for patients with multiple long-term conditions (MLTC): how to do it
Through our research we have developed tools and guidance to help general practices introduce personalised annual reviews for patients with multiple long-term conditions.
Background
Many people have multiple long-term conditions needing regular review. At present most general practices review each of these conditions in isolation. This is inconvenient for patients and inefficient for practices. These disease-specific reviews fail to treat the patient as a whole person and can neglect to address the health problems that bother the patient most.
We advocate doing a ‘whole-person’ annual review, instead of multiple disease-focused reviews. Our research indicates that this provides a better patient experience and it is also more fulfilling for clinicians. Many people think it is a good idea, but introducing this change is difficult and raises a number of issues.
Tools and guidance
Please watch the video, Personalised annual reviews for patients with multiple long-term conditions: how to do it, or read our guidance, How to introduce single person-centred annual review (PDF, 219kB), which includes links to a range of tools:
- An outline structure for the review
- How to plan for the change, including guidance about process mapping
- Details of a computerised template for Emis practices to support the review
- A search to enable Emis practices to Identify patients with three or more multiple long-term conditions who would benefit from review
- Guidance about staff training, including a curriculum to help staff self-assess their training needs
- An audit search so that Emis practices that use the template can monitor their progress
- A list of issues that practice face when changing to personalised annual reviews, and suggestions for how to address them.
Further information
See also:
- Project web page on the NIHR Applied Research Collaboration West (NIHR ARC West) website: Improving review appointments for people with long-term conditions - the PP4M study
- Improving review appointments for people with long-term conditions (PDF, 330kB) - ARC BITE (NIHR ARC West) - a summary of the research findings from the PP4M study
- Multimorbidity and long-term conditions research from the Centre for Academic Primary Care.
- Watch the PP4M study video:
