The criteria has changed for this year, the indicator wording is:
DEM004 (002): The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months – 39 points (35-70%)
If the patient has an advanced care plan in place from secondary care, this will be acceptable. For those patients who do not have a care plan, the practice will be required to develop an acceptable care plan.
The review of the patient care plan regardless of who has initiated the plan is a face to face review in primary care – you cannot use a hospital review to achieve this indicator.
The new Read codes are as follows:
|Dementia advance care plan agreed||8CSA.||XabEk|
|Dementia care plan||8CMZ.||XaaBZ|
|Review of dementia advance care plan||8CMG2||XabEl|
|Dementia advance care plan declined||8IAe0||XabEi|
|Dementia advance care plan review declined||8IAe2||XacM2|
|Dementia care plan review declined||8CMZ3||XacJ0|
A Face to face review:
The Face to Face care plan/Advanced care plan review should have the following key issues:-
An appropriate physical, mental health and social review for the patient
A record of the patient’s wishes for the future.
Communication and co-ordination arrangements with secondary care (if applicable), identification of the patient’s carer(s):
- Obtain appropriate permissions to authorise the practice to speak directly to the nominated carer(s) and provide details of support services available to the patient and their family, if applicable, the carer’s needs for information commensurate with the stage of the illness and his or her and the patient’s health and social care needs,
- As appropriate, the carer should be included in the care plan or advanced care plan discussions,
- If applicable, the impact of caring on the care-giver,
- Offer the carer a health check98 to address any physical and mental health impacts, including signposting to any other relevant services to support their health and wellbeing