PIFU is not a new concept and it is one that PKB knows a lot about. PKB has been supporting patient lead follow-up for many years, supporting and empowering patients to manage their own conditions and enabling shared data and supporting self-management.

PIFU is a way trusts organise care, giving patients and their carers more flexibility over the timing of their follow-up appointments. PKB has been successfully supporting trusts to reduce waiting times and do virtual clinics before the PIFU term came along. You can read more about how here.

Workflow

Use cases 

Swansea Bay

Rheumatology team

Patients have access to their blood results into their records, thus reducing the need for outpatient appointments and saving time for more urgent cases. Patients can also order prescriptions through secure messaging with the clinical team.

Outcomes

• 75% reduction in face-to-face outpatient appointments (reduced from 4 quarterly to 1 annual appointment)

• 264 appointments saved from 88 patients (creating capacity) 

• Patients empowered with the information and tools to:
  - communicate with clinical teams when needed
  - manage medication reviews and prescriptions remotely
  - understand the importance of blood monitoring for their dermatological condition.

Dermatology team

Systemic patients typically have blood results 4 times a year. With the introduction of PKB, patients can be seen once a year - they are sent all 4 blood forms for the year, and patients message the team with their results in order for them to obtain their repeat prescriptions, removing the need for the appointment.

75% of face-to-face appointments were reduced, as were phone calls. PIFU workflow was able to reduce appointments from every three months to once a year. 

Bedfordshire Hospitals NHS FT 

Inflammatory Bowel Disease Service

1⁄3 of patients moved to a PKB remote pathway where patients initiate the follow-up. Released 1,100 appointment slots from a patient group of ~600. Empowered patients with self-management, remote monitoring capabilities and virtual consultations. “Not only does it save patients having to come into hospital but also allows us to see when patients flare up, so we can see them within 48 hours rather than generate clinic appointments.”

East Sussex Healthcare Trust 

Uro-oncology

Patients are actively engaged with the uro-oncology team via PKB and can view blood test results, complete a symptom tracker questionnaire and read information, which is then reviewed by the nurse who gives feedback either on the result and symptoms are acceptable, meaning, no appointment required, or the they organise an appointment if clinical input is needed. This has resulted in less time reviewing blood tests and freeing up appointment slots.

Key features 

There are key PKB features all services validating waiting lists can use. A list of them is below.

Questionnaires 

Teams can use PKB’s FHIR trigger API to automate sending questionnaires to service users and they can use PKB’s FHIR API to extract completed responses back into their Organisation's electronic patient record (EPR) for review.

Patients can initiate a questionnaire by clicking start questionnaire on their homepage or directly within the NHS App. Once completed the questionnaire can be sent to a professional or team.

PKB's advanced questionnaire functionality

The features include:

• Scoring and calculations

• Branching, allowing patients to complete the parts of the questionnaire that are relevant to them

• Coded fields questionnaires can be mapped to clinical codes

• Patients can save drafts

• Send questionnaires to patients who aren’t registered or already in your team

Questionnaire templates

• Pre Op Questionnaire 

• Prehab - Healthy Eating Questionnaire

• Quality of life questionnaires

• Pain questionnaire

• Enhance recovery after surgery questionnaire

• Capturing Digital Outcome Measures

Messaging 

• Patients have access to message their healthcare team (saving time on the phone)

• The Admin team can triage messages. Either resolving or passing onto another speciality team

• Universal Messaging is the ability for patients to message clinical and non-clinical teams

• Team-based messaging allows teams to automatically receive secure messages and questionnaires as a group rather than as individuals

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Library 

Use the Library feature to share clinically verified information with patients. Effective guidance and instructions to empower self-care can reduce the need for face-to-face care.

• A wealth of resources

• Online patient leaflets

• Support group information

• Videos

Care plans 

Remote monitoring

Use Plans to create personalised care plans, provide patients with information and guidance on how to manage their conditions, and understand when and how to access the right clinical input when required.

PKB care plans can be used at every stage of a patient's condition journey, below are some of the care plan templates being used and templates that can be created.

• Living Well for Longer

• Condition information and resource care plans

• Monitoring condition plan (for example cardiology monitoring care plan)

• Rehab, physical activity and musculoskeletal health

• Goals setting care plan

• Peri-operative care plans

Remote monitoring - escalation points

Agreed escalation points can be created using a Traffic Light System within the Care Plans feature to help patients understand when something isn’t right and when they should seek support.

All professionals i.e. nurse specialists, can track changes, intervene and create personalised self-management plans to support patients to manage their condition based on their symptoms.

Symptom tracking

Use the Symptom Tracker to allow patients to plot their symptoms, enabling them to notice changes in their condition and act upon them.

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Appointments 

• Appointment letters and appointments sent to PKB via integration

• Manually entered appointments

Share test results

Use the Test Results to educate patients about their condition and to help them recognise when changes may be required in how they manage aspects of their care.

Evidence collected from the NHS organisations using PKB shows that access to test results improves care coordination, reduces anxiety for patients and means time spent during appointments is used more effectively.

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SMART goal

Reduce the number of appointments for the ………. team by Sept 2024 (12 months post team go live) from (current appointments) to ( %) by adding all patients to a PIFU pathway (if they fit the criteria), schedule questionnaires to be sent ….. Current appointment rates are (%). 12 months post go live, the team compared appointment rates of patients with and without a PKB record. It is a local NHS priority to add patients to a digital PIFU pathway to reduce waiting lists and to save money.

Case study

• Dermatology in Swansea case study: Transforming the face of traditional dermatology services

• Inflammatory bowel disease service case study: Better care leads to savings in Inflammatory Bowel Disease

Further information

• PKB PIFU solution: Where and how PKB supports trusts deliver PIFU pathways