Chronic Disease Management and Annual Health Reviews

Here is an outline of the new plan

• Every patient with a long-term health condition will have their individual circumstances reviewed by a GP or a nurse trained in their health condition(s).
• An individualised plan will be made for each patient requiring regular monitoring or review, taking into account their condition(s) and prescribed treatment(s), what monitoring has taken place in the past 18 months and the urgency of arranging further appointments.
• The practice will contact each patient by telephone or letter when their annual Chronic Disease Management appointment is due.
• The appointment will be with a nurse and you are encouraged to bring along any questions or information about your condition(s). 
• At the Annual Chronic Disease Management Appointment, the nurse will ask you questions about your condition, discuss your general health, and answer any questions you may have about your condition. 
• If there are questions that the nurses cannot answer, they will either contact the GP to discuss the matter with them or advise you to book an appointment to do this yourself.
• If any measurements or tests are undertaken, the results will be recorded in your notes.
• There will be a booked slot for your GP or a nurse trained in the management of your condition(s) to review the notes and results from your Annual Chronic Disease Management Appointment, review your prescriptions and create a new plan for your management over the following year. They will contact you if they feel it is necessary, based on the information gathered at your Annual Chronic Disease Management Appointment.
• You can still book appointments with your GP via reception if you need to discuss something regarding your chronic conditions or general health.

For the following types of appointments, you are asked to have specific items or information available. Please click on the appropriate link below if you have been asked to attend to review one of these issues.

Annual Health Reviews for patients with Learning Disability or Autistic Spectrum Disorder

Asthma Reviews

COPD Reviews

Blood Pressure Monitoring

Diabetes Reviews

Video Calls

1. Read this PDF with instructions and if you need more help or you have difficulty reading the attached PDF file, go to https://nhs.attendanywhere.com/callers. On this website you can also watch instructional videos and make a test call to check your equipment works. Please test your equipment at least 30 minutes before your appointment so that you are ready when the time comes.
2. Log in to the virtual waiting room 5 minutes before your appointment by clicking on this link https://nhsattend.vc/nhsg/CamphillMP. If it doesn’t open in the correct browser on your device (Google Chrome or in Safari), you need to copy and paste it into the correct browser.
3. Fill in your details, read the notices and wait in the virtual waiting room until the GP or nurse connects the call to speak to you. If there is a significant delay, we will try to update you via the messaging system, so watch your screen for updates. If nobody appears to speak to you within 20 minutes of your appointment time, please call reception by phone on 0345 375 2020.