Why

GP surgeries have started to change their workflow in light of the new NHS Long Term Plan. This change is necessary to meet the NHS Long Term Contract requirements and provide enhanced, personalised, and preventative care for their local community. Additionally, the goal is to cover the social needs of their patients through prevention projects.

What

GP surgeries are adopting a new care model that brings together a range of health and social care professionals. This involves expanding their non-medical workforce and organising multi-disciplinary meetings to deliver personalised care within Primary Care settings. Using PKB will help Primary Care to apply the new care model with a long term digital solution giving patients the tools to manage their health and social care.

How to save time and increase efficiency

PKB supports the NHS Long Term Plan to enable digital access to NHS services and help patients and their carers manage their health. This not only benefits patients but also reduces overall costs for practices. Digital correspondence can cut down missed appointments and significantly reduce postage costs. Digital care plans and questionnaires can support self-management, help reduce appointment lengths, and give healthcare professionals access to symptoms, measurements, and test results from other organisations caring for the patients.

Key PKB features

Key PKB features that all GP practices can use with their patients to support the new care model are listed below.

Messaging

• Patients have access to message the GP practice, and health coach team (saving time on the phone)

• The Admin team can triage messages.  Either resolving or passing on to the GP, practice nurse, practice manager or health coach

• 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

• Central library for advice, services and information about the practice 

• Disease and condition information with advice and resources

• Treatment plans, for example, a rehab program with videos and advice a patient needs to watch and read each week

• Rehabilitation information

• Advice on Living well, including exercise, healthy eating, quitting smoking and alcohol recommendations

• Details and links to National and local support groups and website

• Treatments options for conditions and pain management

• A directory that shows available activities in the local  area

• National Health Campaigns such as Stoptober and dry Jan

• A cost-effective way to signpost patients 

• Allows all the workforce using the same directory with the most up-to-date information

• Increasing health literacy of patients to allow them to manage their own health 

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Care plans

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

• Me and my goals care plans 

• Monitoring condition plan (here is an example of a cardiology monitoring care plan)

• Mental health well-being information and resource

• Rehab, physical activity and musculoskeletal health

• Goals setting care plan

• Generic support care plans from physiotherapy, podiatry, occupational therapy, OT teams

• 8-Week Orthopaedic Prehabilitation plan

• Enhanced recovery care plan

• Maternity care plan examples 

• Sleep Care Plan

• My care and support plan

Questionnaires

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.

Teams using the questionnaire tool can ensure the outcome of clinical reviews is recorded and the patient has a copy. Teams can also identify patients suitable for virtual appointments or pre-operative assessment questionnaires.

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

Add and View Data

• Patients can view hospitals and GP data  where integration with PKB has been set up

• Data can include blood tests, x-ray reports, clinic and appointment letters, appointments and discharge summaries 

• Patients can add information themselves, including operations, allergies and conditions 

• Patients can track key measurements and add any symptoms related to their conditions

Workflow

GP refers patients who need Care Coordinator Service and patients get added to the Care Coordinator PKB team in the GP practice. Patients who most benefits from personalised care are patients with chronic disease and have involvement in more than four services.

EMIS Data

PKB integrates with EMIS software to automatically receive all patients' from EMIS into PKB records, and to show all data from PKB to users of EMIS. To set this up, read the PKB-EMIS deployment Process

EMIS Extract Service

PKB has a partnership with EMIS Health in order to deliver more collaborative, seamless health care for you and your Patients. EMIS Extract Services enables PKB customers to securely obtain raw primary care data to improve patient care and assist with cost-saving reductions. For more information on EMIS extract service and configuration please visit here.

EMIS Single sign-on

Allow a GP to click through from EMIS Web and see any data held on their patients in Patients Knows Best (PKB) without having to log into PKB each time. PKB will open seamlessly within EMIS Web for ease of use. For more information on EMIS single sign-on please visit here.

Data transfer from EMIS to PKB

The data transfer from EMIS is in the form of a csv file which represents an export of EMIS database tables. One file is received per table on a daily basis. When a practice initiates the extract service bulk data is received for all regular patients with NHS numbers. PKB processes a subset of files to transfer data which includes:

First Stage

Second Stage

Future Stage

Case study

Aspley Medical Centre and Beechdale Care Home Affiliation - Nottinghamshire has been using PKB in Primary Care to link GP surgeries with care homes.

The use of PKB has also helped residents receive their medications faster “Using PKB to request medication has also quickened the response from the GP practice and the pharmacy. Before we would email and have to wait sometimes 2-3 days before receiving the medication but now, we get a message from the practice saying the GP has actioned this within a couple of hours, meaning the resident will receive their medication sometimes on the same day.”