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Recipe Name

Identify eligible patients for the Life! program meeting that meet the risk criteria c3

Rationale

The following inclusion criteria will present in a patient determine eligibility for the Life! program:

  • Age 18 years and above
  • One or more of the following pre-existing conditions
  • CVD
  • CKD
  • GDM
  • PCOS
  • Prediabetes
  • Familial Hypercholesterolemia
  • Serum Total Cholesterol > 7.5mmol/L
  • Systolic BP of ≥ 180 mmHg or Diastolic BP ≥110mmHg.

    The exclusion criteria includes patients with:
  • Diabetes
  • Active Cancer
  • Cardiovascular Disease (CVD) diagnosis in the last 3 months

Target Population

Patients at high risk who can be recommended for/are eligible for the Life! program

CAT Starting Point

  1. CAT Open – CAT4 view (all reports) loaded.
  2. Population extract loaded and extract pane "hidden".
  3. Optional Only: Filter Pane Open and under the 'General' tab, "Active Patients (3x < 2 years)" selected. *The decision to select either "Active" or "Any" patient is left to the practice to make

Main Steps to set common inclusion and exclusion criteria:

...

To identify patients with CKD:

  1. Follow main steps 1-4.
  2. In Reports Pane, select 'Disease Report' and select 'Chronic Kidney Disease (CKD)'.



       3. Click 'Report' button to view list of patients meeting these criteria.

...

To identify patients with GDM or Familial Hypercholesterolemia:

  1. Follow main steps 1-3.
  2. For GDM, select 'Chronic tab' and under Diabetes select 'Gestational'.



      3. For Familial Hypercholesterolemia, select 'Other' tab and check the box beside 'Yes' under Familial Hypercholesterolemia.

...

Click on Recalculate button and then 'View Population' button to view list of patients meeting these criteria.

List can be saved/printed or be sent a SMS/Voicemail Recall via the Patient Reidentification window.


To identify patients with Serum Total Cholesterol > 7.5 mmol/L:

  1. Follow main steps 1-4
  2. In the Reports pane, select 'Pathology' report, 'Lipids' tab and then 'Cholesterol' tab.



       3. List can be saved/printed or be sent a SMS/Voicemail Recall via the Patient Reidentification window.

       4. Select >7.5 and click on 'Report' button to view list of patients meeting these criteria.

...

  1. Follow main steps 1-4.
  2. In the Reports pane, select 'Measures' report and then 'BP' tab.
  3. Select >140/90 and click on 'Report' button to view list of patients meeting these criteria.



      4. List can be saved/printed or be sent a SMS/Voicemail Recall via the Patient Reidentification window.

...