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The Future of Primary Health Care in Europe, Southampton 2008 Improving Chronic Conditions Management in Wales - -

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The Future of Primary Health Care in Europe, Southampton 2008 Improving Chronic Conditions Management in Wales - -

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    1. The Future of Primary Health Care in Europe, Southampton 2008 Improving Chronic Conditions Management in Wales - - a proactive, planned and integrated approach -experiences from Wales Helen Howson Senior Health Strategy Advisor / Head of Community Health Strategy Welsh Assembly Government September 2008

    2. The Problem

    3. Birth rate and Population trends

    4. Current Prevalence – future trends ?

    5. The Timebomb There is a higher proportion of reported limiting long-term illness (23%) compared with England (18%), Scotland and Northern Ireland (20%) 1/3 of adults report having at least one chronic condition Most commonly reported chronic conditions treated in Wales are arthritis (14%), followed by respiratory conditions (13%) and chronic heart conditions (9%) Considerable geographical variations in reported long term limiting illness, ranging from 19% in Cardiff to 30% in Merthyr Intensive users of in patient services have on average 3 chronic conditions Estimated by 2014 a 20% increase in over 65s with a chronic condition A Profile of Long-Term and Chronic Conditions in Wales (June 2005)http://www2.nphs.wales.nhs.uk:8080

    6. Projected Trends - EA’s

    9. The Solutions

    10. What do we want to achieve? AIM Improve health and well being in the population and reduce the incidence and impact of chronic conditions OBJECTIVES Promote wellbeing in the community Prevent and delay the onset and early deterioration of chronic conditions in the community Improve quality of life for people living with chronic conditions Deliver services and support closer to people and their communities Reduce the impact on secondary care, emergency admissions, length of stay and readmission rates Increase self management, independence, and the participation of people with chronic conditions and their carers Improve prescribing and medicines management Improve economic activity with increased return to work rate

    11. CCM Population Projections for Wales

    12. From fragmentation to integration

    14. How do we achieve it ? The Model and Framework for Action across Wales

    15. Clarity, Purpose and Direction Knowing what we want to achieve Knowing how we will get there Learning from each other Building on experiences and expertise Focused and resourced Top down and bottom up support

    16. Developments to date Profile of Chronic Conditions in Wales An Overview of the Evidence on Effective Service Models in Chronic Disease Management Quality and Outcomes Frameworks in primary care National Service Frameworks – diabetes, CHD Service Development and Commissioning Directives for Arthritis, Respiratory, Epilepsy, Pain CCM Model and Framework for Wales CCM Service Improvement Plan

    18. CCM Service Improvement Plan Generic CCM approach Proactive , planned and managed Integrated service planning and delivery Partnerships – organisations, people, professionals Sustained service improvements Risk stratification of population Care coordination Mainstream for whole population CCM Local Action Plan’s – April 2008

    19. Drivers for Change – Bottom Up & Top Down - National & Local Action CCM Service Improvement Plan – maturity matrix CCM Transitional Funding to pump prime local changes CCM National Demonstrators SAFF targets

    20. Tools and other Support PRISM Generic Care Pathways Local Action Plans R&D Public Health Strategic Framework for CCM Planning Guidance

    21. Monitoring and Evaluation Established a 3 year monitoring and evaluation framework of CCM with support from WORD Determine baseline data process and outcome evaluation indicators National and Local evaluation Framework Local support and advice Addressing evidence gaps – patient experience

    22. Thank you Any Questions? The Future of Primary Health Care in Europe, Southampton 2008 Improving Chronic Conditions Management in Wales - - a proactive, planned and integrated approach -experiences from Wales

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