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You are here: Home / Resources / SystmOne Resource Centre / Long Term Condition Management / Recall Recovery System

Recall Recovery System

The Recall Recovery system was designed in light of the 2020 Covid-19 pandemic but could be used for any situation where LTC reviews have become backlogged. (There is also a linked system for recovery for drugs which require monitoring Drug Requiring Monitoring System) 

The system is designed for use by practices using three principle recall systems: 

  1. The CDRC integrated LTC recall system 
  2. A system relying on recording of review SNOMED codes for individual disease e.g. diabetes annual review 
  3. Systems using disease specific recalls 

For each system a series of reports are available. (CDRC > Recall Setup > Recall Recovery ……….) 

Recall Recovery 
Recall Recovery 
Recall Recovery 
Recall Recovery 
Recall Recovery 
Recall Recovery 
Recall Recovery 
Recall Recovery 
Recall Recovery 
Recall Recovery 
1 0 L TC Recall - Recall overdue (not housebound or palliative) # 
1 01 L TC Recall - Recall overdue (not housebound or palliative) due invite # 
1 011 L TC Recall - Recall overdue (not housebound or palliative) due invite - f2f likely* 
1 012 L TC Recall - Recall overdue (not housebound or palliative) due invite - consider remote # 
1 02 L TC Recall - Recall overdue (not housebound or palliative) - had three invites # 
1 M L TC Recall - Recall overdue (housebound or palliative) # 
1 2 L TC Recall- Recall overdue 6m (not housebound or palliative) # 
1 21 L TC Recall - Recall overdue 6m (not housebound or palliative) Diabetes +/- CKD # 
1 21 L TC Recall - Recall overdue 6m (not housebound or palliative) Without diabetes (unless in remission) # 
1 3 L TC Recall- Recall overdue 6m (housebound or palliative) # 
Recall Recovery- 2TJ L TC and no review code (not housebound or palliative) # 
Recall Recovery- 2TJ1 L TC and no review code (not housebound or palliative) due invite # 
Recall Recovery- 2TJ1 1 L TC and no review code (not housebound or palliative) due invite - f2f likely # 
Recall Recovery- 2TJ1 2 L TC and no review code (not housebound or palliative) due invite - consider remote # 
Recall Recovery- 2112 L TC and no review code (not housebound or palliative) - had three invites # 
Recall Recovery- 311 Disease Specific Recall - Recall overdue (not housebound or palliative) # 
Recall Recovery- 3111 Disease Specific Recall - Recall overdue (not housebound or palliative) due invite # 
Recall Recovery- 3111 1 Disease Specific Recall - Recall overdue (not housebound or palliative) due invite - f2f likely # 
Recall Recovery- 3111 2 Disease Specific Recall - Recall overdue (not housebound or palliative) due invite - consider remote # 
Recall Recovery- 3112 Disease Specific Recall - Recall overdue (not housebound or palliative) - had three invites # 
Recall Recovery- 3M Disease Specific Recall - Recall overdue (housebound or palliative) #
  • x.0 – Patients whose review is overdue (excluding those who are housebound or on the palliative care list) 
  • x.01 – As above who haven’t had an invite in the last month (this report identifies people to be invited at monthly intervals for three months) 
  • x.011 – Patients in x.01 who are likely to need face to face appointment (see below) 
  • x.012 – Patients in x.01 who might be able to have a telephone or video review 
  • x.02 – Patients who have not responded after three invitations 
  • x.1 – Patients whose review is overdue who are housebound or on the palliative care list 

The first four reports can be broken down to show additional details such as those who are shielded, date of recall, patients who are high priority for review (see Appendix 2 – Higher Risk Patients below). Details of how to use the breakdown options are shown below. 

For practices using the CDRC LTC system there are also reports to identify those patients overdue a six month review (1.2-1.3) subdivided into those with diabetes (+/-CKD) and those with CKD requiring 6 monthly assessment (without diabetes). 

There are also disease specific sets of reports for QoF conditions in the disease specific folders if you wish to concentrate on one disease only e.g. CDRC Quality > Cardiac 

AF - Recall Recovery 1 a - L TC System 3m overdue, higher risk 
AF - Recall Recovery 1 - L TC System 3m overdue, higher risk not excepted 
AF - Recall Recovery 2TJ - Has AF and no coded review (last 18 months) 
AF - Recall Recovery 2M 
- Has AF and no coded review (last 18 months) not excepted 
AF - Recall Recovery 21 - Has AF and no coded review (last 15 months) higher risk 
AF - Recall Recovery 2G - Has AF and no coded review (last 15 months) higher risk not excepted 
AF - Recall Recovery 24 - Has AF and no coded review (last 13 months) 
AF - Recall Recovery 311 - Recall pending 6m overdue 
AF - Recall Recovery 3M 
- Recall pending 6m overdue not excepted # 
AF - Recall Recovery 31 - Recall pending 3m overdue, higher risk* 
AF - Recall Recovery - Recall pending 3m overdue, higher risk not excepted #

Coding Invitations 

It is strongly recommended that you use the following code when inviting patients for LTC reviews: 

Quality and Outcomes Framework quality indicator-related care invitation (procedure) Y1f8f 

This code is used by the system to count who has been invited and how many times.  It has the additional advantage of removing patients from the QoF denominator once patients have been invited twice, which will improve end of year QoF performance.  NB although the patient is removed from the QoF denominator, TPP have set up new icons that continue to alert the user to QoF issues unlike other QoF exceptions. 

Conditions Covered

  1. For the CDRC LTC Recall system any patients with the LTC Recall will be included 
  2. For the system looking for review codes the following conditions are covered: Asthma, atrial fibrillation, CHD, CKD, COPD, dementia, diabetes, epilepsy, heart failure, hypertension, hypothyroidism, learning disability, serious mental illness, peripheral arterial disease, rheumatoid arthritis and stroke. 
  3. For the system using disease specific recalls the relevant recalls that ‘count’ are shown in Appendix 1 – Disease Specific Recalls, see below. Additional recalls could be added if needed. 

Using the Breakdown Option

Right click on the search and choose Breakdown then tick the following options as required.  Then click Refresh 

Report Breakdown Option Purpose 
Demographics First name, surname etc  
Recall Recovery * – QoF Invite 1/2/3 (last 6m) # Event details – event date Shows the date of recent LTC review invites 
Recall Recovery * – Higher risk patients # Strategic reporting ID – Patient ID Shows patients at higher risk who might be prioritised for review 
Recall Recovery * – Shielded # Strategic reporting ID – Patient ID On the Covid-19 shielding register 
Has future appointment Appointment date, clinician etc. Allows you to see if the patient already has an appointment 
CDRC LTC Recall System Only (reports 1.x)   
Recall Recovery * – LTC Recall – Recall Overdue # Recalls – Recall date Allows you to order the patients by how overdue their review is 
Disease Specific Recall System Only (reports 3.x)   
Recall Recovery * – Disease Specific Recall – Recall overdue # Recalls – Recall type and Recall date Allows you to order the patients by how overdue their review is 

Face to Face vs Remote Reviews

The following conditions are assumed to require at least some face to face assessment (to carry out blood tests or physical examination): Atrial fibrillation, CHD, CKD, diabetes, heart failure, hypertension, hypothyroidism, learning disability, serious mental illness, peripheral arterial disease and stroke. 

If patients have the following conditions they are also included in the group likely to need face to face contact: NAFLD, high risk of diabetes, familial hypercholesterolaemia.  (NB in systems 2 and 3 these conditions are not specifically included in the reports of patients to recall but do affect location of review. e.g. if a patient has NAFLD only, they will not be included in any of the reports.  If a patient has asthma and NAFLD they will be included in the reports but with a recommendation for face to face review).  

The following conditions are generally more suited to remote review: Asthma, COPD, dementia, epilepsy, rheumatoid arthritis 

Appendices

Appendix 1 – Disease Specific Recalls

Disease specific recalls that are counted in the recall recovery system: 

  • Asthma 
  • Asthma annual review 
  • Atrial fibrillation 
  • Atrial Fibrillation Annual Review 
  • CHD
  • CHD Annual Review 
  • CHD Monitoring 
  • CHRONIC DISEASE MANAGEMENT 
  • Chronic Disease Monitoring 
  • Chronic Disease Review 
  • Chronic Disease Review 12m 
  • Chronic Disease Review 3m 
  • Chronic Disease Review 6m 
  • CKD 
  • COPD 
  • COPD ANNUAL REVIEW 
  • Coronary Heart Disease annual review 
  • DEMENTIA 
  • Dementia Annual Review 
  • Dementia Review 
  • Diabetes 
  • Diabetes 3month Review 
  • Diabetes 6 month check 
  • Diabetes 6 month review 
  • Diabetes 6month review 
  • Diabetes Annual Review 
  • DIABETES MELLITUS 
  • Diabetic 6 month review 
  • Diabetic Annual Review 
  • Epilepsy 
  • Heart Failure 
  • Heart Failure Annual Review 
  • Hypertension 
  • HYPERTENSION ANNUAL REVIEW 
  • Hypertension Monitoring 
  • Hypothyroidism 
  • hypothyroidism annual review 
  • Learning Disabilities 
  • PVD Monitoring 
  • Rheumatoid Annual Review 
  • Rheumatoid Arthritis 
  • Rheumatoid Arthritis Annual Review 
  • Rheumatoid Arthritis Monitoring 
  • Stroke 

Appendix 2 – Higher Risk Patients
 Higher Risk 
Any LTC >=4 DNAs in the past 2 years Significantly overdue drug monitoring 
Asthma >6 SABA in last 12 months  Last ACT score >20 LABA on repeat and no ICS High dose ICS LAMA Aminophylline Biologics Likely moderately severe asthma Exacerbations (>2 in 12, severe/admission last 12m, life threatening) Exacerbation in last 2y but no ICS Concordance issue – LABA, LAMA Exceeding usual quantities of long acting inhalers 
AF Anticoagulation should be considered 
CHD BP > 150/90 Poor concordance (anticoagulants, antiplatelets, betablocker, ccb, diuretics, RAS drugs, statin) 
CKD CKD G3aA3, G3bA2,3, G4/5 
COPD Severe COPD MRC 4+5 >=3 exacerbations in the last year >=3 course of prednisolone in the last year CAT score >20 Concordance issues with long term inhalers 
Diabetes Scoring system (1 point for each of) Hba1c>100 Hba1c >75  Hba1c >58 BP >=150/90 High risk feet Mod risk feet ACR >3  ACR>30 Lipid Total Cholesterol>5 Poor concordance hypoglycaemics Poor concordance lipid lowering Poor concordance RAS drugs Poor concordance diuretics Poor concordance CCBs  Score >=3 
Heart failure NYHA 3 and 4 Sicubatril Eplerenone, spironolactone 
Hypertension BP>=150/90 Poor concordance beta blockers Poor concordance alpha blockers Poor concordance lipid lowering Poor concordance RAS drugs Poor concordance diuretics Poor concordance CCBs 
Learning disability BMI <19 or >40 On antidepressants, antipsychotics, anxiolytics, hypnotics, opioids, gabapentinoids, lithium Two or more (non LD) LTCs No health check for 2 years History of aspiration pneumonia or PEG Any drug monitoring is significantly overdue 
PAD BP > 150/90 Poor concordance (anticoagulants, antiplatelets, betablocker, ccb, diuretics, RAS drugs, statin) 
Stroke BP > 150/90 Poor concordance (anticoagulants, antiplatelets, betablocker, ccb, diuretics, RAS drugs, statin) 

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