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Long Term Conditions Collaborative

Long Term Conditions Collaborative . Susan Bishop, National Programme Manager Susan.bishop2@scotland.gsi.gov.uk   07825861323 Dr Anne Hendry, National Clinical Lead Anne.Hendry@lanarkshire.scot.nhs.uk   07734290106. 1900 – 1950 Infectious disease. 1950 – 2000 Episodic acute care.

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Long Term Conditions Collaborative

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  1. Long Term Conditions Collaborative Susan Bishop, National Programme Manager Susan.bishop2@scotland.gsi.gov.uk  07825861323 Dr Anne Hendry, National Clinical Lead Anne.Hendry@lanarkshire.scot.nhs.uk 07734290106

  2. 1900 – 1950 Infectious disease 1950 – 2000 Episodic acute care Changing health challenges

  3. Challenge for the third Millenium Long Term Conditions

  4. 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

  5. Dejuvenation

  6. Prevalence by Age

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. Impact of Case/ Care Management • DoH ‘Evercare’ programme • Community Matrons • Potential to reduce unscheduled care utilisation remains unproven

  14. 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

  15. 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

  16. 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

  17. Long Term Conditions Collaborative Susan Bishop, National Programme Manager Susan.bishop2@scotland.gsi.gov.uk  07825861323 Dr Anne Hendry, National Clinical Lead Anne.Hendry@lanarkshire.scot.nhs.uk 07734290106

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