CEG Workshop QOF 2019 What are we going

CEG Workshop QOF 2019 What are we going

CEG Workshop QOF 2019 What are we going to cover? QOF Changes to clinical indicators Personalised Care Adjustment (old exception reporting) Quality Improvement Domains - How CEG can help! Not covering: Workload issues/Indemnity/Digital Technologies/Funding/Primary Care Networks QOF - Three main weaknesses recognised Can feel like tick box medicine Scheme not kept up with changing evidence base

Exception reporting too crude and lack transparency QOF Points remains the same QOF Points (559) 2018-19 27 QOF Points (559) 2019-20 97 74 11 Clinical Public Health Additional Clinical 95 Public Health

435 Additional 379 Quality Improvement Point Value 187.74 per QOF Point National average practice population of 8,479 What is happening in 2019/2020 QOF? 28 indicators RETIRING worth 175 pts

15 indicators NEW/Replacement worth 101 pts (diabetes, BP control, and cervical screening) NEW Quality Improvement Domain worth 74 pts Exception reporting replaced with Clinical Domain No changes in: Atrial Fibrillation 29pts Heart Failure 29pts

Asthma 45pts Depression 10pts Cancer 11pts CKD 6pts Epilepsy 1pt Learning Disability 4pts Rheumatoid Arthritis 6pts CHD No loss of points Indicator Points CHD001. The contractor establishes and maintains a register of patients with coronary heart disease 4 CHD002. The percentage of patients with CHD in whom the last BP (measured in preceding 12mths) is 150/90 mmHg or less

17 53-93 CHD005. The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken 7 56-96 CHD007. The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 August to 31 March 7 56-96

CHD008. The percentage of patients aged 79 years or under with CHD in whom the last blood pressure reading (measured in preceding 12 months is 140/90 or less 12 40-77 CHD009. The percentage of patients aged 80 5 years or over with CHD in whom last blood pressure reading (measured in preceding 12 months is Thresh old 46-86 Hypertension 1 point lost Indicator

Points HYP001. The contractor establishes and maintains 6 a register of patients with established hypertension HYP006. The percentage of patients with 20 hypertension in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less HYP003. The percentage of patients aged 79 14 years or under with hypertension in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90mmHg or less HYP007. The percentage of patients aged 80 5 years and over with hypertension in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90mmHg or less Threshol

d 45-80 40-77 40-80 Good news City and Hackney LTC1-E01Y Hypertension with BP <=140/90 [82%] 86% Stroke/TIA Register lost 2 points Indicator Points Threshol

d STIA001. The contractor establishes and maintains a register of patients with stroke or TIA 2 STIA008. The percentage of patients with a stroke or TIA (diagnosed on or after 1 April 2014) who have a record of a referral for further investigation between 3 months before or 1 month after the date of the latest recorded or stroke or the first TIA 2 45-80 STIA003. The percentage of patients with a history of a stroke or TIA in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less

5 40-75 STIA007. The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken 4 57-97 STIA009. The percentage of patients with stroke or TIA who 2 have had influenza immunisation in the preceding 1 August to 31 March 55-95 STIA010. The percentage of patients aged 79 years or 3 under with a history of stroke or TIA in whom the last blood

pressure reading (measured in the preceding 12 months) 40-73 Peripheral Arterial Disease lost 4 points Indicator Point Thresho s ld PAD001. The contractor establishes and maintains a register of patients with peripheral arterial disease 2 PAD002. The percentage of patients with peripheral arterial disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less

2 40-90 PAD003. The percentage of patients with peripheral arterial disease with a record in the preceding 12 months that aspirin or an alternative anti-platelet is being taken 2 40-90 Diabetes lost 16 points Indicator Points DM017. The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed

DM002. The percentage of patients with diabetes on the register, in whom the last blood pressure reading (measured in the preceding 12months) is 150/90 mmHg or less DM003. The percentage of patients with diabetes on the register, in whom the last blood pressure reading (measured in the preceding 12months) is 140/80 mmHg or less DM004. The percentage of patients with diabetes on the register, whose last measured total cholesterol (measured within the preceding 12months is 5 mmol or less DM006. The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs) DM007. The percentage of patients with diabetes on the register, in whom the last IFCC-HbA1c is 59mmol/mol or less in the preceding 12months 6 Threshol ds

8 53-93 10 38-78 6 40-75 3 57-97 17 Indicator Points

Threshold DM008. The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 64mmol/mol or less in the preceding 12months DM009. The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75mmol/mol or less in the preceding 12months DM012. The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12 months DM014. The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register DM018. The percentage of patients with diabetes, on

the register, who have had influenza immunisation in the preceding 1 August to 31 March 8 43-83 10 52-92 4 50-90 11 40-90 3 55-95

Indicator Points Threshold DM019. The percentage of patients with diabetes without moderate or severe frailty, on the register, in whom the last blood pressure reading (measured in the preceding 12months) is 140/80 mmHg or less DM020. The percentage of patients with diabetes without moderate or severe frailty on the register, in whom the last IFCC-HbA1c is 58mmol/mol or less in the preceding 12months DM021. The percentage of patients with diabetes with moderate or severe frailty on the register, in whom the last IFCC-HbA1c is 75mmol/mol or less in the preceding 12months DM022. The percentage of patients with diabetes aged 40 years and over, with no history of CVD and without moderate or severe frailty, who are currently

treated with a statin. (excluding patients with type 2 diabetes and a CVD risk score of <10% recorded in the preceding 3 years) DM023. The percentage of patients with diabetes and a history of CVD (excluding haemorrhagic stroke) who are currently treated with a statin. 10 38-78 17 35-75 10 52-92 4 50-90

2 50-90 A word about Frailty 2017/18 Frailty identification and care part of GP contract Routine identification of frailty aged 65 and over Stratify into mild/moderate/severe Used eFI tool clinical judgement Frailty not recorded will make denominators for diabetes more difficult

Severe Frailty CR MR FA Deliver a clinical review Annual medication review Falls Assessment LTC Template COPD lost 10 points Indicator Point s COPD001. The contractor establishes and maintains a register of patients with COPD

3 Thresho ld COPD002. The percentage of patients with 5 COPD (diagnosed on or after 1 April 2011) in whom the diagnosis has been confirmed by post bronchodilator spirometry between 3 months before and 12 months after entering on to the register 45-80 COPD003. The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months

9 50-90 COPD004. The percentage of patients with COPD with a record of FEV1 in the preceding 12 months 7 40-75 COPD005. The percentage of patients with COPD and MRC dyspnoea grade 3 at any time in the preceding 12months with a record of 5 40-90 Indicator

Points COPD007. The percentage of patients with 6 COPD who have had influenza immunisation in the preceding 1 August to 31 March COPD008. The percentage of patients with 2 COPD and Medical Research Council (MRC) dyspnoea scale 3 at any time in the preceding 12 months, with a subsequent record of an offer of referral to a pulmonary rehabilitation programme (excluding those who have previously attended a pulmonary rehabilitation programme) Threshold 57-97 40-90 Dementia lost 6 points Indicator

Points DEM001. The contractor establishes and maintains a 5 register of patients diagnosed with dementia DEM004. The percentage of patients diagnosed with 39 dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months DEM005. The percentage of patients with a new 6 diagnosis of dementia recorded in the preceding 1 April to 31 March with a record of FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded between 12 months before or 6 months after entering on to the register Threshold 35-70

45-80 Mental Health lost 8 points Indicator Points MH001. The contractor establishes and maintains a register of patients with schizophrenia, bipolar affective disorder and other psychoses and other patients on lithium therapy 4 Payment Threshol ds MH002. The percentage of patients with 6 schizophrenia, bipolar affective disorder and other

psychoses who have a comprehensive care plan documented in the record, in the preceding 12 months, agreed between individuals, their family and/or carers as appropriate 40-90 MH003. The percentage of patients with 4 schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months 50-90 MH006. The percentage of patients with 4 schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the 50-90

Mental Health lost 8 points Indicator MH007. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 12 months Poin ts 4 Threshol d 50-90 MH008. The percentage of women aged 25 or 5 over and who have not attained the age of 65 with schizophrenia, bipolar affective disorder and other psychoses whose notes record that a cervical screening test has been performed in the preceding 5 years

45-80 MH009. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 9 months 1 50-90 MH010. The percentage of patients on lithium therapy with lithium levels in the therapeutic range in the preceding 4 months 2 50-90 BMI>30 in SMI Population 31% of SMI patients

have a record of BMI>=30 compared to 13% in general population Remission from SMI Only use remission codes: No record of antipsychotic medication No mental health in-patient episodes; and no secondary or community care mental health follow-up within the last five years Osteoporosis lost 6 points Indicator Points Threshold OST004. The contractor establishes and maintains a register of patients: 1. Aged 50 or over and who have not

attained the age of 75 with a record of a fragility fracture on or after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and 2. Aged 75 or over with a record of a fragility fracture 3 OST002.The percentage of patients aged 50 or over, and who have not attained the age of 75, with a fragility fracture on or after 1 April 2012, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone sparing agent 3 30-60 OST005. The percentage of patients aged 75 3

or over with a record of a fragility fracture on or after 1 April 2014 and a diagnosis of osteoporosis, who are currently treated with 30-60 Palliative Care Register lost 3 points Indicator Point Threshold s PC001. The contractor establishes and maintains a register of all patients in need of palliative care/support irrespective of age 3 PC002. The contractor has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative

care register are discussed 3 Public Health Domain No changes in: Cardiovascular Disease Primary Prevention 10 pts Blood Pressure -15 pts Obesity 8pts Public Health Domain Smoking lost 2 points Indicator Point Thresh s old SMOK002. The percentage of patients with any or any

combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 12 months 25 50-90 SMOK003. The contractor supports patients who smoke in stopping smoking by a strategy which includes providing literature and offering appropriate therapy 2 SMOK004. The percentage of patients aged 15 or over 12 who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 24 months

40-90 SMOK005. The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months 56-96 25 Public Health Additional Contraception lost 7 points Indicator Points CON001. The contractor establishes and maintains a register of women aged 54 or under who have

been prescribed any method of contraception at least once in the last year, or other clinically appropriate interval e.g. last 5 years for an IUS 4 CON003. The percentage of women, on the register prescribed emergency hormonal contraception one or more times in the preceding 12months by the contractor who have received information from the contractor about LARC at the time or within one month of the prescription 3 Thresh old 50-90 Public Health Cervical Screening lost 9 points

Threshol Indicator Points CS001. The contractor has a protocol that is in line with national guidance agreed with NHS CB for the management of cervical screening, which includes staff training, management of patient call/recall, exception reporting and the regular monitoring of inadequate sample rates 7 CS002. The percentage of women aged 25 or over and who have not attained the age of 65 whose notes record that a cervical screening test has been performed in the preceding 5 years 11

CS004. The contractor has a policy for auditing its cervical screening service and performs an audit of inadequate cervical screening tests in relation to individual sample takers at least every 2 years 2 CS005. The proportion of women eligible for screening and aged 25-49 years at the end of period reported whose notes record that an adequate cervical screening test has been performed in the previous 3 years and 6 months 7 45-80 CS006. The proportion of women eligible for screening 4

45-80 d 45-80 Personalised Care Adjustment End of life care Intervention is clinically unsuitable As per current existing rules Newly diagnosed or newly registered

Medicine intolerance Allergies Contraindications Echo Spirometry Reversibility Structured Education Pulmonary Rehab Specific service not available Patient Choice Five

Reasons Did not respond to offers of care Informed dissent Specific codes to single indicators Actual invitations sent to patients 2 now not 3 except cervical screening PCA As with exception reporting applying a

PCA to patient record will remove patient from indicator denominator if QOF defined intervention has not been delivered. Clear auditable reasons coded or entered in free text on patient record for PCA Note about coding Intervention Clinically Unsuitable Generic codes patient unsuitable apply to all indicators and more specific codes more codes will become available in time. Patient chosen not to receive intervention Generic codes informed

dissent. New Quality Improvement Domain 74 points Prescribing Safety 37 points End of Life Care 37 points Prescribing Safety Indicator Points Achievem ent Threshol d QI001. The contractor can demonstrate

continuous quality improvement activity focused upon prescribing safety as specified in the QOF Guidance 27 N/A QI002. The contractor has participated in 10 network activity to regularly share and discuss learning from QI activity as specified in the QOF Guidance. This would usually include participating in a minimum of two peer review meetings N/A Improvements in prescribing safety

NSAIDs in patients with significant risk of complications such as GI bleeding Monitor of potentially toxic medications such as lithium prescribing Valproate and pregnancy prevention Practices will need to: Example - Valproate E.g. Baseline audit shows that not all girls/women of childbearing potential are recorded as using highly effective contraception e.g. IUD/IUS/IMP CEG Search

Set up a SMART outcome SPECIFIC MEASURABLE ACHIEVABLE RELEVANT TIME BOUND SMART Eg. Increase from 17% to x% of patients using highly effective contraception End of Life Care Indicator Points

Achievem ent Threshol d QI003. The contractor can demonstrate continuous quality improvement activity focused on end of life care as specified in the QOF Guidance 27 N/A QI004. The contractor has participated in 10 network activity to regularly share and discuss learning from QI activity as specified in the QOF Guidance. This would usually include participating in a minimum of two peer review meetings

N/A Improvement in the following measures Start with assessment of quality of care provided Identify quality improvement goal Increase of proportion of people on register Increase of proportion offered personalised care plan discussions

Increase in proportion of care givers identified and given support System to receive feedback on Example Measure 3 Baseline audit 10% of carer identified on practice support register were contacted and given info on grief/bereavement within 1 month SMART outcome: Increase 10% to X% of family members given supported within X wks/mths of the person on the register dying. Implement the plan

Involve the whole practice team Engage with colleagues in community Check progress on plan Discuss in network peer review meetings minimum two meetings Any further questions Further information https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/

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