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Long Term Conditions Collaborative . Susan Bishop, National Programme Manager [email protected]   07825861323 Dr Anne Hendry, National Clinical Lead [email protected]   07734290106. 1900 – 1950 Infectious disease. 1950 – 2000 Episodic acute care.

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Long term conditions collaborative

Long Term Conditions Collaborative

Susan Bishop, National Programme Manager

[email protected]  07825861323

Dr Anne Hendry, National Clinical Lead

[email protected] 07734290106


Changing health challenges

1900 – 1950

Infectious disease

1950 – 2000

Episodic acute care

Changing health challenges



Long term condition
Long term condition

  • “condition that requires ongoing medical care, limits what one can do, and is likely to last longer than one year.”

    NHS Scotland 2005




Whole system burden of ltcs
Whole System Burden of LTCs

  • 80% of all GP consultations

  • 60% of all inpatient bed days

  • 70% of all emergency admissions

  • 80% of all prescribed medicines

  • Home care, equipment and housing support

  • Carer support issues

  • Long Term Care needs


Models of care current future

Acute conditions

Hospital centred

Doctor dependent

Episodic

Disjointed

Reactive

Passive patient

Self care infrequent

Carers undervalued

Low tech

Long term conditions

Embedded in communities

Team based

Continuous care

Integrated care

Preventative care

Patient as partner

Self care facilitated

Carers supported

High tech

Models of careCurrent Future


Population model
Population model

Care Management

Level 3

Complex co-morbidity 3 – 5%

Level 2

DiseaseManagement

Poorly controlled single disease 15 – 20%

Professional Care

Self Care

Level 1

Supported Self Care

Well controlled (70-80% of LTC population)

Population Wide Prevention, Health Improvement & Health Promotion


Improvement support team collaborative
Improvement & Support Team Collaborative

“Support NHS Scotland deliver sustainable improvements in patient centred services”

  • Creates time and opportunity

  • Supports understanding of care delivery processes and clinical systems

  • Supports local teams to take action and test changes

  • Supports development of capability and capacity and sustaining and spreading good practice


Developing ltc programme
Developing LTC programme

  • Building regional infrastructure

  • Alignment with Mental Health and 18 Weeks Referral to Treatment Programmes

  • Inclusion of Primary Care Collaborative

  • 3 Workstreams

    - self management

    - specialist care

    - complex care


Specialist care disease case management
Specialist Care Disease (Case) Management

  • Proactive systematic approach

  • Protocol driven care through agreed pathways

  • Time limited or goal defined exit criteria

  • Care delivered by team

  • Medicines management focus

  • Care pathways reflect whole patient journey

  • eg Heart Failure / diabetes / stroke / COPD


Impact of case care management
Impact of Case/ Care Management

  • DoH ‘Evercare’ programme

  • Community Matrons

  • Potential to reduce unscheduled care utilisation remains unproven


Joint working infrastructure
Joint Working Infrastructure

  • Aligned Community nursing teams

  • Responsive joint services

  • Rapid access clinics

  • Intermediate Care models

  • SPARRA and Anticipatory care

  • Systematic support for care homes


Work in progress
Work in Progress

  • Scoping programme and dashboard of improvement measures - CHP Toolkit, HEAT, Community Care Outcomes, Service user experience

  • Establishing a multi-agency reference group and shared learning network

  • IST Training and awareness events


Next steps
Next Steps

  • Continue Whole System engagement

  • Meet with local and national groups

  • Develop partnership with LTCAS

  • Connect with related health and community care programmes

  • Joint Launch April 24th with Mental Health Collaborative


Long term conditions collaborative1

Long Term Conditions Collaborative

Susan Bishop, National Programme Manager

[email protected]  07825861323

Dr Anne Hendry, National Clinical Lead

[email protected] 07734290106


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