Audit Nurse Role – Woodlands Medical Practice
Susanna Robinson has been a nurse for more than 50 years and with previous experience of undertaking audit work she was ideally suited to the role, which in 2003 when it was created was to deal with administration the Quality and Outcomes Framework (QOF) practices complete.
This role led to Susanna undertaking summarising for the practice which soon developed, due to her interests in care provision, into a broader and more in depth role.
Her role now encompasses a vast variety of aspects including coding, initiating recalls, liaison with GPs re patient’s needs, signposting patients to appropriate tertiary services, connecting carers with support and services, summarising, cervical screening recall programme, training new staff on coding and much more, making Woodlands Medical Practice the surgery who refers the most patients into pathway services. (see appendix A for full details of the role)
Susanna is the carer’s champion and takes this aspect of her role very seriously, providing aftercare support to some of the practices most vulnerable patients and their carer’s.
She has received countless letters of thanks from patients and from organisations regarding the work she does and has recently received a Highly Commended CCG General Practice Award for Going the Extra Mile.
Trish, the GPs and staff at the practice all see this role as a pivotal one and Susanna regularly has conversations with GP’s and staff of all levels who raise concerns with her about a patient or carer and Susanna is able to take the time and care needed to approach patients or their carers/loved ones to discuss what issues they may be encountering and how she may be able to facilitate helping them.
With her clinical knowledge and background Susanna is able to support patient’s with confidence and signpost them efficiently and effectively to access the right services to assist them. Once contacted patients use Susanna as their point of contact for the practice and the numerous testimonials she holds in practice are testament to the impact the work that she and the practice have done has had on their patients.
Whilst the direct impact of such a role may be difficult to quantify against targets the practice has created a log of the scores of patients it has assisted through the role.
The more qualitative case study information which the practice has collated regarding the positive effect the work of the role has had on its patients speaks for itself. Here are a small sample of the examples of the patients this approach has helped:
- Patient A – (brother not EoL), gave brief support session to refer to NCC for assistive technology – a medication carousel. Worth a try to see if he can use this for meds and not accidentally over medicate.
- Patient B – (registered blind not EoL) – arranged follow up appt and transport for last weds at dermatology clinic but he was admitted to hospital during night previous. Will rebook when I know he is home. This is the second time he has been admitted to hospital prior to clinic appts
- Patient C – Diagnosed with malignancy. Lives with wife who has Dementia. Being admitted to hospital for procedure, son concerned re mother being unable to cope. Pathways gave ‘golden Line’ number to son to call if that eventuality occurs and is visiting on a regular basis.
- Patient D – Was a very frequent caller to Out of hours services and asking for doctors to visit. Referred to Age Uk.
Was visited by one of the team and supported for 8 weeks initially. Since the first visit patient has not made any further calls to out of hours services and remains happier.
Age Uk called to see her again and although she said that her arthritis was playing her up, she seemed a lot better.
Social Services have finally carried out an assessment on her sister and are in the process of setting a care package up to assist with washing and dressing. This will certainly ease the pressure on patient.
We discussed the issue of patient hand washing both of their clothes but despite my best efforts patient has declined a washing machine! However, I have managed to find a local laundrette service that will collect their washing weekly and do this for them, which patient was very keen to try.
I will contact patient again in 2-3 weeks time to ensure the care package is working, and hope that this has a positive knock on effect to the 999 calls she was making.
- Patient E – Patient was referred to the Pathways carer Support Service due to concerns around benefits and finances.
Patient has end stage COPD, Emphysema and is very frail. Despite of his deteriorating health, he does some caring duties for his severely disabled wife – so essentially they are a co caring couple.
Patient has very poor literacy skills, and due to his respiratory problems, has trouble being understood, especially on the telephone.
When the support worker arrived there were a number of issues and support needs:-
- DLA Benefit
- Domiciliary Care Invoices
- Pension Credit
- Council Tax Support
Patient hoards letters and paperwork and so the support worker had to work through an extensive amount of paperwork to find the necessary documents to give support with.
Patient stated he was expecting his DLA to increase to high rate care & mobility as per the GP instruction several weeks ago, but nothing had happened
The support worker discovered that the document the GP was referring to was a DS1500 – (a document that fast tracks and awards high rate benefit within the last 6 months of life). This document should have been sent off to the DWP and patient had not understood that this is what he should have done. The support worker contacted DLA, despatched the DS1500 document to DLA, with a covering letter to appeal that his benefit at high rate be awarded from the date of the DS1500 despite that being many weeks previous. This is at the discretion of the decision makers at panel – but patient was successful and was awarded high rate benefit and backdate.
Domiciliary Care Invoices & Pension Credit
Patient stated that he was receiving large invoices from Notts County Council for joint care packages at a total of £41.69 each per week that he could not afford and so had not paid any, and was facing legal proceedings for payment
The support worker contacted the Debt Recovery Team at Notts County Council and discussed the concerns re invoices. Through negotiation the Debt Recovery Advisor suspended patient and his wife’s accounts until the Support Worker could discover why the invoices were being generated.
The support Worker found a copy of patients Financial Assessment for care package contribution and made contact with Notts County Council Financial Assessment Team to be informed that the figures were accurate and he would not require a review.
The support worker established that some figures on the Financial Assessment for Pension Credit (both savings & guaranteed) were based on eligibility and not ACTUAL income. This had massively over inflated his weekly income and hence generated the invoices of £41.69 each per week.
Contact was made with Pension Credit Department to be informed that patient was not actually in receipt of any pension credit although there was entitlement. A Pension Credit assessment was completed and patient was awarded a very small amount.
The support worker then liaised again with Notts County Council Financial Assessment Team to inform that patients pension credit award was significantly less than the eligibility figures on the original assessment. Evidence Documents were sent to review patients charges and the invoices should have been £8.52 each per week as opposed to £41.69. The Support worker then had to further liaise to have all invoices backdated and reworked. After this was successfully completed the support worker assisted patient to enable him to pay all back dated invoices and then set up a direct debit to manage future invoices.
Council Tax Support
Patient E also had arrears with his council tax because his Council Tax Support had been ceased. The support worker discovered that the local council had sent several letters to complete a review, but patient had not responded and so the benefit was stopped. Because it had ceased patient had not paid 2 months council tax because he was unsure whether he should pay the full amount. The support worker contacted the local Council and made arrangements for an assessment worker to conduct a home visit to obtain the necessary financial documents to review support. This was completed with the aid of the support worker during the home assessment and after calculation council tax support was re-instated and back dated. Patient then paid his council tax and was no longer in arrears.
Patient requires ongoing support to ensure he maintains his financial affairs.
Patient F – Referral from pics team nurse as carer experiencing difficulties caring for her mother due to family dynamics. Safeguarding alerts in past as carers father has history of both physical and mental abuse towards both daughters and wife (cared for )
Risk Assessments implemented …
Staff built up a rapport with Carer over time to enable her to gain trust in staff.
Support to access carers allowance and requested Carers assessment.
Liaised with referrer regularly for a “How thing are going “update.
Emotional support following death of mother
Discussed long term plans as Carer had given up employment to provide care to mother.
Supported to address debts and finances as property being repossessed. Signposted to CAB and supported to attend first meeting.
Supported to visit GP due to bereavement and own health issues.
Supported to access correct benefits once Carers Allowance withdrawn.
Support to consider housing options …social housing or private rent or to move into Fathers home.
Support to attend local council to make homeless application.
Support to request help from community services with removals of belongings.
Emotional Support after final repossession order from court.
Support to ensure client moved into alternative accommodation safely. Supported to notify relevant organisations of new address (council benefits etc. )
Patient G – Referral from GP for female patient S aged 52 with cancer diagnosis.
S lived in social housing property with her daughter and two year old grandson. Her second son was living out of area due to work commitments but gave up full time employment to share caring role with his sister.
Supported to access housing, council tax and state benefits after ds1500 issued by surgery and SSP had expired.
Support to liaise with housing provider regarding outstanding repairs that were having a detrimental impact on the whole family.
Advice on Carers right given to daughter as employers were questioning leave due to pending hospital appointments and treatment for cared for.
Advice on alternative child care arrangements for grandson.
Supported son as his benefits were sanctioned twice due to reasons given for moving out of area and leaving full time employment.
Ongoing Emotional support to both carers and cared for as constant caring role was having a negative impact on both social and personal wellbeing.
Signposted to support group and community transport for cared for.
Liaised with surgery regarding changing needs of cared for. (Mc Millan, O.T . GP home and surgery visits)
Support to access alternative housing due to constant changing needs of cared for.
Support to access community services regarding removal of belongings into new property and donation to charity of unwanted belongings.
After death……. Support to family members as cared for passed away before moving into new home.
Support to both son and daughter to gain alternative housing, budget money, and organise removals via community services and local charity.
Supported son to gain full time employment.
Susanna’s Audits , QOF work, Carer Support etc
• Coding of letters re new qof, new diagnoses, initiating 3/12 recall processes in holistic appointment sparing fashion, adding qof requirements to diagnosis. Informing gps re new medications started or others stopped. Mindful of bloods etc required
• Summarise all new patient notes, initiating recalls. Extensive interrogation of letters, notes, cards, other members of household for family history, possible Safeguarding etc . Ensuring patients are not lost to recalls if on annual cancer follow up for instance. Offer gp apt asap to those with chronic conditions, organise bloods, ecg if not done, NHS health checks where appropriate etc etc
• All new Diabetics referred electronically to Diabetic retinal screening, task PNs re new or newly diagnosed diabetics. List for pneumovax /flu vax if not had
• Robust cervical screening process, checking Open Exeter, forwarding to Cytology lead . Coding all previous cervical smear history. Adding reason for irregular screening if known. Highlighting colposcopy, HPV, CIN 1,2.3 etc. Ensure recall follows current protocol. Smear recall will include brief history of Lletz. CIn, HPV etc
• Hysterectomised patients : ensuring histology includes cervix removal. Contacting gynaecologist if this is uncertain
• Teaching all new staff, all levels re importance of accurate coding, carer support, qof, IT, palliative care processes, etc
• Attend Prism and Palliative care meetings
• Liaise with Matron re her patients and our requirements
• Frequent contact with Age Uk and Pathways re carer support, maintaining spreadsheet record of all my referrals.
• Update Pathways referrals so admin can inform team re patients deceased
• Maintenance of palliative database, EPaccs, inviting MDT to meetings etc. Database updated the month before the next meeting and any patient who is ‘stable’ Iand who has not attended or been seen by a clinician I ring up and offer a gp apt, or visit
• Maintenance of QOF board on a monthly basis. Daily qof monitoring to achieve our 12 years 100%
• In all aspects I offer carer support to patients identified as may be in need, especially palliative or dementia patients. All coded as Supportive care –for audit purposes
• All EOL are on EPACCS, and have been offered pathways support
• Most Dementia patients in own homes have also been offered Age UK support. All new diagnoses are coded by myself usually and at that point I will try to offer Age uk support. I also ensure qof bloods are managed and annual reviews started withing3 /12. Age UK write to me with their findings and processes undertaken. I update patients notes with this information and forward email to Trish for reference and safekeeping
• Carer Register maintained, also the Housebound Register
• I remind all staff on a regular basis to task me when they see a patient who needs support, I then contact the patient and offer whichever service is appropriate
• Patients with Care Plans –I monitor their recalls and remind gps to see and update
• Safeguarding items I see in children’s notes [adults also at times] I task to GP lead to consider flagging notes and adding to our Register. Since may very few notes have arrived for our newly registered babies, children and adults [awaiting approx. 400]. I have created a report to monitor new registrations on a daily basis and audit the notes in order to look for Safeguarding [6 last week] and initiate recalls for chronic disease patients, or if in care homes, consider if EOL and code etc
• Depression patients, I monitor and if not added for interim review, I will ring and offer apt. If unable, I organise a standard letter – 3 invites within 8 weeks , without hassling the patient.
• Cancer care reviews I monitor and organise
• QOF research is always ongoing, attending courses twice annually and seminars
• Splenectomy patient database monitored, and updated, and required vaccinations identified and given with reminders added.
• Exacerbation of Asthma -3/12 audits to ensure gp has seen patient
• Impaired Glucose tolerance, and Gestational Diabetes patients –annual ‘at risk diabetes’ bloods recall instigated
• At imes, when qof points are not happening as they should, I liase with Dr Pound and ask for an alert or pop up reminder to be added
• I ask also for certain status markers to be added –ie out of area patients, or same name patients, so notes are flagged
• I deal with the monthly retinal screening return –new diagnoses, pregnant diabetic females [need 3/12 screening] deceased, change of address, new diabetic patients etc
• Assisting other practices with qof problem solving or carer support details
• Summarised all pantiles patients notes in one year
• Assisited in CQC visit KCPCC !
• Assist admin re mental health and Dementia patient recalls –identifying which bloods if any needed for their apt and completing ICE form for same
• Formulated recently a palliative care process for new gps, registrars, F!.2s etc
• I email DNR forms to OOH if patient not on Epaccs
• Daily discussion with PM re work in hand, new qof rules, etc
• Managemen of learning disability register, recalls, appointments, coding, liasing with LD nurses [gold standard]
• Audits for gps as asked
• Managing my own audits to look for missing qof points- ie work done but not coded onto template [usually community ],
• Retrospective audits as in diary; some are
• Coded Claudication, but not on PVD Register
• New Hypertension diagnosis with no CVD risk
• Diabetic Foot checks done but not coded foot risk
• EOL but not known to EPACCs, or vice versa
• Smokers not advised to stop coded
• Fractures but not coded fragility where low impact
• On Thyroxine but not coded Hypothyroidism
• Gestational Diabetes with no annual at risk blood recall in place
• LVSD but not coded Heart failure
• ECG; AF but not coded AF
• Children with Diabetes
• Raised blood glucose or Hba1c but not identified as Diabetic
• Notes received but not summarised
• Lives out of area but not coded as such
• Still coded pregnant but has delivered
• High level Read codes
• Care Home patients with no care plan
• Care home patients with no DNR
• Alcohol audit not done for new patients
• New patient here but never received notes
• Housebound but not EOL
• Over 90 but not EOL
• Fraility index high but not EOL
• CKD5,COPD end stage, Heart failure but not coded EOL
• Palliative but not referred to Pathways
• Dementia but not referred to Age uk
• Diabetes and Pregnant
• In new year, awareness that qof prompts will not be apparent –ie for Cancer care, depression etc –conduct own searches
• Smears done –but no result
• Rheumatoid Arthritis –but no pneumovax
• Accessible information Audits
• On EOL but no DNR in place, or resus status
• Identified that when patients were deregistered as moved but wanted to stay on here and re-registered –notes were not sent away [so they were not in effect, missing notes] but recalls automatically were removed. But they were not reinstated
• I did a robust audit of all out of area patients, ensured they were coded as such then audited each one to reinstate recalls as best as I could.
• Then audited all females of smear age who dd not have a recall in place –checked with Open Exeter and reinstated a correct recall –tasked then to cytology lead to confirm correct
• Audits done recently –menorrhagia, IMB, Warfarin, Osteoporosis
• Audit re Care Home patients who do not have a DNR or Resus status
• Audit of CHD /other chronic disease patients who do not have a recall in place
• Care Home patient ensure all have DNR’s where appropriate and care plans