Long Term Conditions
Hilltops Medical Centre is pleased to announce the introduction of a new Long Term Conditions clinic. This aims to improve the care we provide for patients with long term conditions by moving away from a reactive, disease-focused, fragmented model of care towards one that is more proactive, holistic and preventive.
We have implemented a new system for calling in our patients for annual reviews of their long term conditions. The change aims to improve the service we offer and by reducing the amount of appointments you may need and avoiding duplication of tests. The system will group all your appointments into one extended appointment with a Healthcare Assistant; during this appointment they will complete an array of different tests and examinations depending on your personal combination of conditions.
The results will then be reviewed by a GP who will decide if you need a follow up appointment which may be with a specialist nurse/clinical pharmacist or GP for review. You may not always be required to come in for a second appointment as your condition may be stable/well controlled.
You will be called each year on the month of your date of birth. If you have multiple conditions then instead of receiving multiple invites throughout the year to attend surgery you will receive one message. The message will have instructions on where to go to book your appointment.
Should you not book an appointment after your first invitation you will be sent another reminder letter. Should you not respond to the invites then the GP will review your notes to decide if it is safe for you to continue your medications without any monitoring or reviews.
We appreciate in this initial change over year you may be invited for an appointment before a full year has elapsed since your last review. We would encourage you to try and attend so that we can spread our reviews over the year and create a system that runs smoothly in the future. If you cannot attend during your birth month as you will be out of the country for a time or for any other reason then please let us know and we may be able to change your review date from your birth month.
If you feel you have had a very recent review or that you have regular reviews at the hospital then please contact us and let us know and a GP can review you notes and decide if you need a review or if it needs postponing to a later month. If you let us know any problems then we can try and correct any errors and make adjustments to accommodate you rather than ignoring the invitations.
Patients That Will Be Invited For Annual Review
Any patients with a diagnosis of one or more of the following conditions will be invited to attend for an appointment:
- Chronic Obstructive Pulmonary Disease
- Chronic heart disease
- Coeliac disease
- Rheumatoid Arthritis
- Atrial Fibrillation
- Chronic Heart Failure
- Peripheral Arterial Disease
- Cerebral Vascular Accidents
- Trans ischemic attacks
- Diabetes Mellitus
- Gestational Diabetes
- Chronic Kidney Disease
- Learning Disability
- Coeliac Disease
- Severe Frailty
- Post-Bariatric Surgery
Please note that patients with asthma, COPD or learning disabilities only will be invited separately to see the specialist clinician directly as they will not need an initial appointment with a HCA. This appointment may be done remotely.
Some conditions such as diabetes and people with a reduced renal function identified on previous tests (also known as chronic kidney disease) may require blood tests at 3/6 or 9 months also. These people will be invited for an interim review which will be an initial blood test only.
Depending on your condition you will be required to have different tests and examinations.
What Will Be Carried Out In Your Review
- Dementia: BP, bloods, height, weight, BMI, smoking status, alcohol intake, well being check
- Diabetes: BP, bloods, foot check, height, weight BMI, smoking, alcohol intake, urine
- Learning Disabilities Assessment: BP, bloods, Smoking, alcohol intake, wellbeing check
- Mental health Reviews: BP, bloods, height, weight, BMI, smoking status, alcohol intake.
- Peripheral Arterial Disease/Heart Disease/Stroke: BP, bloods, lifestyle review
- Post Bariatric Surgery: BP, bloods
- Severe Frailty: BP, bloods, wellbeing check
- Rheumatoid Arthritis: BP, bloods
Further Information On Long Term Conditions
Please visit the links below for more information on these conditions: