Maiya's Impact on Long-Term Condition Management in a GP Practice

Mrs S is a 74 year old lady with high blood pressure, diabetes, hypothyroidism and rheumatoid arthritis for which she takes metformin, ramipril, thyroxine and methotrexate. Her GP practice operate an annual review system based on her birthday, which is in March.

The practice invites her for a review of her blood pressure and diabetes in March for her birthday review, her Hba1C is 65. In April she has blood tests for methotrexate monitoring. In May her thyroxine prescriptions run out and she is invited for blood tests which take place in June. Her 3 monthly methotrexate blood tests are taken again in July, November and February with a 6-month diabetes review in October. 

In April the practice swaps and uses Maiya to organise their long-term condition and medication management. In May Mrs S is recalled for methotrexate monitoring and because she is coming anyway Maiya organises her thyroxine monitoring at the same time. Using the rules set by the practice, Maiya has identified her as someone whose diabetes could be better controlled so in August when she comes for her methotrexate bloods she also has a diabetes review, including foot check. She has her methotrexate bloods in November. She attends again in February and her Birthday review is done at the same time.

By swapping to Maiya the practice has reduced the number of appointments by HCA by 3 (7->4), maintained the same number of nurse appointments but achieved greater QOF achievement.