The Personalised Proactive Whiteboard is a digital tool used by GP practices to identify and support groups of people at risk of health deterioration.
After identifying at risk groups, the aim is to provide a proactive approach to coordinating care, with a purpose of providing personalised care and avoiding a crisis.
What is the Personalised Proactive Whiteboard (PPW)?
The Personalised Proactive Whiteboard is a search tool based on coding within the GP clinical systems to be used by Frailty Practitioners and Care Coordinators working in Primary Care in Gloucestershire.
It has 2 functions:
- Case Finding Reports that are run to identify cohorts of people from primary care codes (e.g. people living with moderate and severe frailty). These reports produce a list of patients.
- ’Whiteboard’ – which contains the list of identified people and the individual interventions recommended to support active care coordination.
The PPW is intended to improve communication, collaboration and personalised care.
The PPW is a key enabler for the delivery of the PCN Frailty and Dementia Proactive Model of Care, directly enabling teams to identify people living with frailty and manage their care through structured care coordination.
At a high level, the PPW provides the following functionality:
When clinical staff perform consultations, they use codes to explain both diagnosis and procedures. The codes are recorded against the patient’s record and allow us to easily identify patients without having to account for spelling or personal terminology.
Users simply run a search (that has been developed by Gloucestershire ICB and GP partners) which captures information about a specific collective group of patients, for example those diagnosed with chronic obstructive pulmonary disease (COPD) and/or dementia or who are having falls, those with a completed “Recommended Summary Plan for Emergency Care and Treatment” (ReSPECT) plan, those with “just in case” (JIC) medication and many others.
Upon completion of the searches, the resulting information is transferred via a report output to an Excel spreadsheet (the Personalised Proactive Whiteboard) where the data can be sorted and filtered as required.
The Personalised Proactive Whiteboard should be used to create an ongoing picture of the patients who are suitable to receive proactive care and as such it provides six ‘tabs’ in which data can be recorded.
What are the benefits of using the PPW?
To the Individual:
- Supports self-management of conditions.
- Promotes “What matters to me” conversations.
- Supports a personalised approach to care.
- Person has a key point of contact to help navigate the system.
To the Workforce:
- Saves GP time.
- Encourages a Multi-Disciplinary Team (MDT) approach.
- Supports the delivery of effective care co-ordination.
- Supports consistency of practice.
- Upskills the workforce.
- Provides a structured, consistent approach for care coordinators.
To the System:
- Adopts a Population Health Management (PHM) approach.
- Increases ability to identify people living with frailty and/or those in the last phase of life.
- Supports PCNs to deliver the requirements of the proactive care framework for people living with frailty.
- Enables a more integrated approach to the deliver of care.
- Supports early intervention.
- Enables flexibility to support local prioritiess
This video explains the purpose of the PPW and its benefits: https://youtu.be/MfmbOF_LrvE
This ‘Patient and Primary Care Experience’ video demonstrates the positive impact of the PPW on patient care: The Whiteboard and Care Co-ordination – A patient story
For care coordinators and practitioners using the PPW or getting ready to go live, further resources to support the implementation of the PPW can be found here: PCN Frailty and Dementia Proactive Model of Care : Intranet – NHS Gloucestershire
Should you wish to know more about the Personalised Proactive Whiteboard project, please email glicb.whiteboardsupportteam@nhs.net
Related information:
PCN Frailty and Dementia Proactive Model of Care : Intranet – NHS Gloucestershire