www.england.nhs.uk

Long TermConditions

Martin McShaneDirector – Domain2Enhancing the quality of life for peoplewith long term conditions

www.england.nhs.uk

The challengesNumber of Conditions1 % self reporting

1 30%2 13%

3+ 10%

The 15 million people in England with long term conditionshave the greatest healthcare needs of the population

(50% of all GP appointments and 70% of all bed days)and their treatment and care absorbs 70% of NHS and

social care budgets in England

1. The percentage of people aged 18 and over self-reporting experiencing long-term conditions in the GP Patient Survey

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Financial and population ‘gearing’

20/09/2014

Primary£200(6.5k)

Community & MH£500

Specialist£300

Acute£1000(330k)

Social CarePublic Health

www.england.nhs.uk

www.england.nhs.uk 6

GP Specialist

1990

Specialist

2014

CAREGAP

Activity

Complexity

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Geology – strata - stratification

Multiple

Single

Preventing

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Intervention - stratification

Individualised

Standardised

Proactive advice

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CPM / PARR Tool for Systematic Risk Profiling to identify risk

Top 0.5%Community Matron /Virtual Ward as part ofMultidisciplinary Team(CommunityGeriatrician, GP, SocialCare, Therapists, Rehab,Domiciliary )

Care Planning andindividual personalisedcare plan

Disease Specialist Inputwhere required fromspecialist communityteams ( COPD, Diabetes)

Telehealth and Tele CarePsychological Support

Planned hospitaladmission , proactive inreach and facilitateddischarge where needed

0.6-5%Intensive disease / casemanagement byspecialist teams as partof the MDT

Telehealth / Telecare

Community SpecialistServices and clinics withMDT support

Care Planning andindividual personalisedcare plan

Planned HospitalAdmission for those whoneed it and facilitateddischarge viaintermediate care toreduce LOS

6-20%Proactive Disease Managementby General Practice supportedby specialist communityservices and teams

Care Planning and individualisedCare plan

Support to Self Manage

Education Programmes

Annual Review

Specialist Medication reviews

Anticipatory Care

Remote monitoring via tele healthwhere appropriate

Patients step up and down as risk profile changes

21% - 100%Proactive Self Care Supportand Management in PrimaryCare

Risk score recorded andreviewed annually

Active Case Finding

Disease Register

Accurate diagnosis

Information Prescriptions

Care Planning

Education relevant topatients needs

Disease prevention andHealth promotion

HIGH RISK / ComplexityLow RISK / ComplexitySmoking Cessation, Health Promotion and Self Care

Admissions Avoidance

Public Health

PopulationwidePrevention

Diseaseawarenesscampaigns

Socialmarketing

Education

Healthpromotion

Schools

Workforce Development, Training and Education

Co-ordinated Social Care

Newark and Sherwood Integrated Model of Care for Long Term Conditions

Special Patient Notes / 24/7 Access to specialist support

Personal Care Navigator / Named Lead

1

2

3

4

Level

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Population system approachLTC Framework:

• Empowered patient and carers• Professional collaboration• Best Practice (clinical and organisational)• Commissioning

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The House of Care

Organisational and clinical supportingprocesses

Engaged,informed

individualsand carers

Health andcare

professionalscommitted topartnership

working

Commissioning

Person-centredcoordinated care

www.england.nhs.uk

The House of Care - Person centred, coordinatedcare at three levels:

National:What can nationalorganisations and policymakers can do to enableconstruction of the Houseof Care at the next twolevels.

Local:How local health economiesensure that the House ofCare involves a wholesystem approach, including‘more than medicine’ offers

Personal:How the House of Care givesprofessionals on the front linea framework for what theyneed to do for patients andask local commissioners tosecure for them

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“Yes, but what has NHS England everdone for us?”

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http://www.england.nhs.uk/house-of-care/

Resources1. Toolkit2. Dashboard3. Infographic4. Improvement programme

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Health and careprofessionalscommitted topartnership

working

Engaged,informed

individuals andcarers

Commissioning

• Joined up care• Culture• Workforce• Technology• Care Co-ordination• Care Planning

• Information and technology• Care Planning• Safety and Experience

• Self management• Information and

Technology• Group and peer

support• Care Planning• Carers

• Service User and Public Involvement• Contracting and procurement

• Needs Assessment and Planning• Joint commissioning of services• Metrics and Evaluation

• Care Planning• Tools and levers

Build my ownhouse

Click on the links for more information abouteach component and use this to build your own

house

• Guidelines, evidence and nationalaudits

• Care Delivery

Organisational and supporting processes

Person-centredcoordinated care

www.england.nhs.uk

Joined-up carePeople living with long term conditions say that they would like careplanned with people who work together to understand them and theircarer(s), put them in control, co-ordinate and deliver services to achieveoutcomes.Ensuring care is designed and delivered around the needs of theindividual is particularly important for people with complex care needs. Back to house

Interdisciplinary workingProfessionals from different

organisations across health and socialcare and the voluntary sector working

closely together ensuring that care feelscoordinated to people living with long

term conditions and their carers.

Key Components• Single point of contact• Multi disciplinary team working• Professionals talk to each other• Services quick and responsive people

are promoted to stay independent andactive

• Care developed around the individualand not the system

Care Transition

Ensuring a seamless transition forpeople with long term conditionsbetween different care settings.

Key Components• Transition following discharge from

hospital• Transition between health and social

care• Transition related to changes in long

term care needs• Transition from children's to adult

services.

Health andcare

professionalscommitted topartnership

working

www.england.nhs.uk

Interdisciplinary Working

ResourcesIntegrated care for patients and populations: Improving outcomes by working together - Areport to the Department of Health and the NHS Future Forum, The Kings Fundhttp://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together

Integrated Care and Support Pioneers programme, NHS IQhttp://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions/integrated-care.aspx

Integrated Care – Better Care Fund – Local Government Associationhttp://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE

Integrated care value case toolkithttp://www.local.gov.uk/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4060433/ARTICLE

ICASE - Integrated Care Support and Exchangehttp://www.icase.org.uk/pg/dashboard

Kings Fund Integrated care: making it happenhttp://www.kingsfund.org.uk/projects/integrated-care-making-it-happen

Year of care, NHS Improving Qualityhttp://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/year-of-care.aspx

Back to joined up care

Health andcare

professionalscommitted topartnership

working

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The soft stuff…is the hard stuff

18

Mindsetsand beliefs

Values

Individualbehaviours

SOURCE: Scott Keller and Colin Price, ‘Performance and Health: An evidence-based approach to transformingyour organisation’, 2010.

Needs(met or unmet)

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Care plan vs Care Planning

A care plan is primarily focused on diseasemanagement; whereas in care planning the focusis on person management

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Care Planning

20/09/2014

www.england.nhs.uk 20/09/2014

Care & Support Planning

“I” statements from National VoicesI work with my team to agree a care and support plan.I know what is in my care and support planI know what to do if things change or go wrong.I have as much control of planning my care and support as I want.I can decide the kind of support I need and how to receive it.My care plan is clearly entered on my record.I have regular reviews of my care and treatment, and of my care andsupport plan.I have regular, comprehensive reviews of my medicines.When something is planned, it happens.I can plan ahead and stay in control in emergencies.I have systems in place to get help at an early stage to avoid a crisis.

(http://www.england.nhs.uk/wp-content/uploads/2013/05/nv-narrative-cc.pdf)

www.england.nhs.uk

Person centredcoordinated care“My care is planned with people whowork together to understand me and mycarer(s), put me in control, co-ordinateand deliver services to achieve my bestoutcomes”

Communication

Information

Decision-makingCare planningTransitions

Mygoals/outcomes

Emergencies

Goal

22

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CommunityCare Primary Care

University/SpecialistFacilities

Social Care

GeneralHospital

ICare

The Future: 2014-2019