Unplanned care DES

To help others manage the unplanned care DES I thought it might be useful sharing my own notes on actioning the plans. Please note I take no responsibility for the accuracy but this is the information I have used and happy to be corrected if anything out of place. Most of my comments revolve around using TPP Systm One as it the system I use.

For Vision please look at this excellent resource made by Dr Jonathon Behr.

Unplanned Admissions DES

I believe EMIS are currently creating their own method for managing the DES but in the meantime it may be worth looking at this link by QoF Masters which has some useful information.

To get payments:

£1.29 per patient up front payment (31.7.14)

Create register using either CCG provided tool, QAdmission or create own. This register will be a minimum of two per cent of the practice’s  registered adult patients (aged 18 and over),  ie practice population 8500k = 170 patients.

Use Read code:

Admission avoidance care started  XaYD1 and Admission avoidance care ended  XaYD2  for adding/ taking off register.

Informing patient of named accountable general practitioner. Xab9D to inform patient (same as over 75 ES).

Admission avoidance care plan agreed . XabFm and Admission avoidance care plan declined  XabFn to record consent.

Could use end of life care register, list of homeless/ temporary lodgings patients, care/ nursing homes patients, mental health register , learning disability register, and/ or safeguarding list.

Include patients under care of community matron service if applicable.

use: At risk of emergency hospital admission . XaXyq code for those may want to add on list that not highlighted by tools or that practices may still need active management.

If not using named lists then things to consider:

? Split allocation by number of partners, or partners and salaried.

? Split by clinical session share or just allocated.

Have an ex-directory number for AE OOH services, ambulance teams and care/nursing homes.

Maybe create an ex-directory number, ie urgent transfer option or personally use a burner (pay as you go) mobile phone so if patients start to abuse number by mistake can change with ease. Also more portable.  (? discuss with phone provider to create income from line- not recommended but suggested by a colleague)

Patients on register to have same day access or follow up

Other urgent services ie mental health etc to have urgent accesses likely on-the day at latest ( maybe use duty doctor??).

Personalised care plan for register patients. Care plan with named GP and clinically appropriate review. Plans agreed by 30th Sept 2014, there after new patients one month after added to register.

The personalised care plan will include as a minimum:

· patient’s name, address, date of birth, contact details and NHS number
· notification if the patient is a nursing or care home resident
· details of the patient’s named accountable GP and care coordinator (if this is
different to the named accountable GP ie community matron if applicable)
· details of any other clinician(s) who play(s) a significant role in the patient’s
care relating to their specific condition(s) e.g. diabetic lead clinician,
respiratory nurse, Macmillan nurse etc.
· confirmation/details of consent given for information sharing, including if a
patient has given permission for a practice to speak directly to their carer(s)
· names and contact details of the patient’s next of kin/main carer/responsible
adult, if applicable
· details of the patient’s condition(s) and significant past medical history
· details of any ongoing medication the patient is prescribed (this may also
include over the counter (OTC) medicines, if relevant) and plans for review
· allergies
· details of any individual requirements or preferences which will aid the care
and support of the individual
· key action points, for example early detection of impending deterioration with
an agreed plan for escalating care, including crisis management
· where possible and as appropriate, signatories of the named GP/care

Could use Reminder function for patients on list for same day telephone apt with allocated or on call GP ?

£0.57 2nd quarter (30.11.14) payment 0.29 for q3 (28.2.15)  and q4 (31.5.15).

Maintain register and identify accountable clinician for new patients. Only a 0.2% variance in reporting allowed based off data from Exeter, so may be suitable to go slightly over the required number especially if your patient population has a high level of mobility.

For final payment of £0.43 per patient at end of year (31.5.15), need to review admissions monthly with plans updated 3m:

Review admissions from care homes.

Use a Read Code for review ie Review of admission avoidance care plan XabFo. New shift for practice meetings

Reviews of patients on register and admissions to see if could have been prevented

Meeting with read code as above. Record info to allow easy auditing for reports.

Post hospital discharge for register patients contact by appropriate person, within 3 working days of receiving the discharge notification.

Record a Read code(Emergency hospital admission 8H2…) for discharges (possibly use a read code formulary) and a code for contact for register patients (read code formulary, template or protocol).

Share info with CCG and area team.


That is a brief annotated review. A link to the more detailed information is found here.

I hope it helps. This is part of my idea of #1careRevolution that through better sharing of information we as a profession can help each other to help ourselves manage the workload pressures.

Education, communication and back Primary Care


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