Last review date 03/02/2023

The Continuity of Care resources are built upon the Foundry Healthcare operational model based around patient segmentation on the basis of need. This was sited in the Fuller Stocktake Report to improve access and keep patients out of hospital by streaming patients using systematic triage and clinical judgement. If you would like to learn more about how to implement the Foundry Healthcare Operational Model then please visit their website for more information and support from their team.

The following RAG statuses and codes are used:

ColourCodeContinuity of Care

General health good
Less important


Chronic long term disease management required 


Chronic long term disease management required: Complex needs

A suite of resources have been made available on Ardens which include:

A Data Entry Template

To access the template, just search for the 'Continuity of Care' template in the bottom left of SystmOne. If you have setup the patient status alerts to show under the patient demographics on SystmOne (see below) then you can just click the icon to open the template as well.

On the template you will see further information including the ability to update the patient's RAG status. There are also links to the Future Care Planning template and to Update the patients usual GP and branch site. A useful view is also included to show the current patient RAG status, along with their registration details and key background information.

To start the process of segmenting your patients Foundry Healthcare we suggest setting up a protocol so that this template launches when saving the patient record. In their system this protocol only triggers for clinicians as they are usually the ones making the decisions about which patient group the patient belongs to. Please follow the link at the top of this article for more information on their system.


Go to Clinical Reporting > Registrations > Continuity of Care to see the list of patients in each RAG status, along with a report for patients who do not currently have a RAG status recorded.

Patient Status Alerts

A number of GP practices currently use the coloured circles as local patient status alerts to identify patients for different purposes. For this reason, the Continuity of Care patient status alerts have not been made to appear system-wide on the patient home screen and under the patient demographics on SystmOne. 

If you wish for the 'Continuity of Care' patient status alerts to appear on the patient home screen and under the patient demographics to show RAG status, please follow the instructions below.

1. Go to Setup > Data Output > Patient Status Alerts 

2. Go to the 'Continuity of Care' folder

3. Copy each of the red, amber and green alerts and change the 'When triggered' to 'Show icon, name and message on patient home' and 'show icon below top-right demographics box'