Long Term Conditions Collaborative

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Long Term Conditions Collaborative

• Susan Bishop, National Programme Manager
• Susan.bishop2_at_scotland.gsi.gov.uk ? ?07825861323
• Dr Anne Hendry, National Clinical Lead
• Anne.Hendry_at_lanarkshire.scot.nhs.uk ??07734290106

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Changing health challenges

• 1900 1950
• Infectious disease

• 1950 2000
• Episodic acute care

• 
  

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Challenge for the third Millenium
Long Term Conditions
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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

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Dejuvenation
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Prevalence by Age
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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

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Models of care Current Future

• Long term conditions
• Embedded in communities
• Team based
• Continuous care
• Integrated care
• Preventative care
• Patient as partner
• Self care facilitated
• Carers supported
• High tech

• Acute conditions
• Hospital centred
• Doctor dependent
• Episodic
• Disjointed
• Reactive
• Passive patient
• Self care infrequent
• Carers undervalued
• Low tech

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Population model
Care Management
Level 3
Complex co-morbidity 3 5
Level 2
Disease Management
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
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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

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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

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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

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Impact of Case/ Care Management

• DoH Evercare programme
• Community Matrons
• Potential to reduce unscheduled care utilisation
  remains unproven

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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

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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

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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

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Long Term Conditions Collaborative

• Susan Bishop, National Programme Manager
• Susan.bishop2_at_scotland.gsi.gov.uk ? ?07825861323
• Dr Anne Hendry, National Clinical Lead
• Anne.Hendry_at_lanarkshire.scot.nhs.uk ??07734290106