Long term conditions

At Cadbury Heath Healthcare we have lots of different ways that we manage patients with long term conditions. Patients with the below conditions will be invited to attend an annual review.

It is very important that you attend for an annual review so we can check that your condition is stable and review if any changes to your treatment are needed.

Patients are invited in for an annual review based on their birth months:

January birth months – Called to attend in April
February birth month – Called to attend in May
March birth month – Called to attend in June
April birth month- Called to attend in April
May birth month – Called to attend in May
June birth month – Called to attend in June
July birth month – Called to attend in July
August birth month – Called to attend in August
September birth month – Called to attend in September
October birth month – Called to attend in October
November birth month – Called to attend in November
December birth month – Called to attend in December

Below is a description of what will be checked at the annual reviews for each condition. If you have multiple conditions we will streamline your appointment so all checks will be done where they can be at one appointment.

Asthma

Patients with asthma will be sent a questionnaire by post or text message to complete. The questionnaire will ask a range of questions to see how stable your asthma is and will collect information about your currently smoking status, number of exacerbations. This will then be reviewed and you will be notified whether you need an review with our Asthma nurse/Pharmacist, or your asthma appears stable. If your asthma changes after doing the questionnaire we ask patients to contact us to book in for a review.

All patients with Asthma should have a action plan. If you do not have one please contact us and we can send this to you.

COPD

Patients with COPD will be sent a questionnaire by post or text message to complete. The questionnaire will ask a range of questions to see how stable your COPD is and will collect information about your currently smoking status and number of exacerbations. This will then be reviewed and you will be notified whether you need an review with our Pharmacist, or your COPD appears stable. If your COPD changes after doing the questionnaire we ask patients to contact us to book in for a review.

Dementia

Patients will be booked to attend for a memory review with our nursing team. The review will then be checked by the GP who will arrange any further follow up as needed.

Diabetes

Patients who have Diabetes(Type 1 or 2) will be invited in for a appointment with a member of the nursing team. During this appointment the nurse will:

Check your current smoking status
Check your weekly alcohol intake
Check your current level of exercise
Take a blood test to check blood sugar level, cholesterol and kidney function.
Take a blood pressure reading, body weight and pulse.
Do a foot examination
Send off a urine sample for testing

You will be asked to book in a follow up appointment with our Diabetic nurse or Pharmacist. If your blood pressure is high in clinic we will ask you to do 7 days of home blood pressure readings.

You will also be invited for Diabetic Eye Screening, please see link for more information Diabetic eye screening – NHS

Heart Failure

Patients who have Heart failure will be invited in for a appointment with a member of the nursing team. During this appointment the nurse will:

Check your current smoking status
Check your weekly alcohol intake
Check your current level of exercise
Take a blood test to check blood sugar level, cholesterol and kidney function.
Take a blood pressure reading, body weight and pulse.
Ask questions in regards to medication and any symptoms such as chest pain and breathlessness
Perform an ECG

Patients are then asked to book an medication review with the Pharmacist. If your blood pressure is high in clinic we will ask you to do 7 days of home blood pressure readings.

Hypertension and Atrial Fibrillation

Patients who have Hypertension (High blood pressure) or AF will be invited in for a appointment with a member of the nursing team. During this appointment the nurse will:

Check your current smoking status
Check your weekly alcohol intake
Check your current level of exercise
Take a blood test to check blood sugar level, cholesterol and kidney function.
Take a blood pressure reading, body weight and pulse.

All of the information from the review is then reviewed and you will be contacted to book follow ups as needed. If your blood pressure is high in clinic we will ask you to do 7 days of home blood pressure readings.

Peripheral arterial disease, Patients who have previously had a Stroke or TIA and Coronary heart disease

Patients who have any of the above conditions will be invited in for a appointment with a member of the nursing team. During this appointment the nurse will:

Check your current smoking status
Check your weekly alcohol intake
Check your current level of exercise
Take a blood test to check blood sugar level, cholesterol and kidney function.
Take a blood pressure reading, body weight and pulse.
Ask questions in regards to medication and any symptoms such as chest pain and breathlessness

All of the information from the review is then reviewed and you will be contacted to book follow ups as needed. If your blood pressure is high in clinic we will ask you to do 7 days of home blood

Pre-diabetes

Patients who have pre-diabetes will be invited in for an annual blood test to check that their blood sugar level is not rising.

Chronic Kidney disease

Patients who have CKD will be invited in for a appointment with a member of the nursing team. During this appointment the nurse will: