Long Term Conditions

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Long Term Conditions

• NHS Lanarkshire Programme
• Dr Anne Hendry

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NHS Lanarkshire
Monklands
Hairmyres
Wishaw General
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Life Expectancy
Griffiths Fitzpatrick. Health Statistics
Quarterly 20019 16-29.
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(No Transcript)
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The Chronic Care Model
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Chronic Care in Lanarkshire
Proactive, responsive managed care
Long Term Conditions Management
Partnership of Patients, Carers, Health,
Housing, Education, Leisure, Social care and
Voluntary Sector
Expensive, reactive, unplanned care
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Integrated Services

• Community Health Partnerships
• Multi-agency Community Planning
• Joint Future Programme
• Managed Clinical Networks

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Managed Clinical Networks
Local network
CHD Stroke Diabetes Vascular
Palliative Care
Local network
5 Area Wide Networks
Strategic Planning Redesign Quality Shared
IMT and Health Improvement group
Local network
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Community Health Partnerships
Regional Planning
Board
corporate departments (strategic support only)
CHP
CHP
CHP
CHP
MCNs
Pan Lanarkshire Services
X
X
X
X
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Community Health
Partnership Health and social
care network
GP hospital Community hospital
Area Team
PC Team
Acute Services Care Homes
PMS
Intermediate Services Day Care Day Hospitals
PC Team
Area Team
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Long Term Conditions management

• Community based
• Patient information
• Supported Self Care
• SIGN Guidelines
• NHS QIS Standards
• GMS Quality Outcome Framework

• Diabetes
• Hypertension
• Asthma / COPD
• Leg ulcers
• Musculoskeletal
• Heart failure ?

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Older Peoples Service
Clinical Communities

• Stroke
• Falls / Hip Fracture prevention
• Dementia
• Comorbidity is the norm
• High burden of disability
• Assessment / rehab care pathways
• Multidisciplinary team care
• Joint health and social care
• Care / case management

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Older Peoples Services 5 Layers

• Core Home Support and Primary Care services
• Community Specialisms
• Coordinated Locality Services
• Local area specialist support / interventions
• Secondary Care Services

• Mainline community services
• Screening / Prevention
• PMS initiatives
• Enhanced service to Care Home
• SSA / joint equipment access
• Day care Services
• Leisure, Voluntary and independent sector
  services
• Rapid Response / Day Hospital ESD /
  Intermediate services
• Specialist Acute assessment / rehab beds /
  clinics

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Disconnected Care Services

• Acute Assessment Beds
• Stroke / Orthopaedic Rehabilitation
• Generic Rehab Services
• Day Hospitals
• Community Rehab
• Early Supported Discharge
• Rapid Response
• Continuing Care Sites
• Intermediate Care Beds

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Integrated Service for Older People Managed
Care Network Model

• Screening and prevention
• Mainline Homecare
• Evening Care
• Alert /Smart Technology
• Carer / Respite Services
• Care Home / Day Care
• Day Hospital / Outreach
• Rapid Response
• Supported Discharge
• GP beds
• Contracted PNH beds
• Community rehab
• Acute Assess/Rehab

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Managed Care Population
Management Model

• Supported Self Care

Older Peoples Service Managed
Care Network
Case Management
Level 3 Most Complex
Level 2 Range of risk
Disease Management
Steered by condition specific MCNs but care
delivered by CHPs
Level 1 Self Care
Health Improvement
Education Lifestyle
Health Promotion Population wide prevention
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NHSL Youth Health Team

• All 321 Lanarkshire
• schools are now
• registered in the
• Health Promoting
• Schools programme

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Diet
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Exercise
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Targeted Interventions

• Emphasis on balance and gait
• Community or hospital based
• Evolving evidence for Tai Chi
• Duration at least 10 weeks

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Patient Education Supported Self Care

• MCNs leading on patient education, advice and
  support
• Peer support groups
• Voluntary Sector partnership
• Expert Patient Programmes

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Home Exercise Programmes
Gait/Balance Get up and go 6m walk and
turn
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ETHoS Project Bob Devenny

• Interprofessional training for patient
• centred collaborative care
• Environment of care delivery
• Transformational Coping strategies
• Holistic care planning ADL and roles
• Own goals and targets
• Service / care intentional and personalised
• Learning not to fix it !

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Stroke Support Service
NHSL / CHSS Stroke Support Team
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Disease Management

• Aims Proactive systematic approach
• Embedded within IT systems
• Protocol and data driven
• Overseen by MCNs but delivered via CHPs
• Defined entry and exclusion criteria
• Evidence based interventions
• Time limited / goal limited ?
• Agreed exit criteria ( up / down)

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Care/Case Management for complex long term
conditions

• Characteristics
• Older people
• Multiple conditions
• Dependency
• Instability
• Polypharmacy
• Frequent admissions

• Challenges
• Risk Stratification
• Screening tools
• Entry and exit criteria
• Competency framework
• Right infrastructure

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NHSL Picture of Health

• 4 Strategic Redesign Projects
• Long Term Conditions
• Older Peoples Care
• Unplanned Care
• Planned Care
• Care management is not a panacea.
• It needs to be delivered within an integrated
  system

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Care Continuum MCN model
Acute care Care home
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A Picture of Health Values
Safe and Effective Quality Care Communication
and Information
Timeous
Patient Centred
Joined up

Community based
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Supporting projects

• NES Project to support Vulnerable Older People
  living in the community
• Risk screening tools for use in community and
  care home settings
• Competency framework for care management
• Entry and exit criteria for programme
• Multidisciplinary Educational Package
• Care Management pilot programmes
• Evaluation

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Long Term Conditions Management QA

• National Framework for Service Change
• Long Term Conditions Action Team project
• To develop a Self assessment tool for CHPs to
• Determine their performance in delivering care
• for people with long term conditions
• N American, WHO Europe and NHS QIS hybrid

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Performance assessment frameworks

• PAF
• JPIAF
• GMS QOF
• NHS QIS
• Healthcare Governance
• Disease specific
• standards
• QA Frameworks for
• MCNs

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QA Framework for MCN NHS QIS Guidance

• Patient journey
• Simple language
• Diagrams/ pathways
• Evidence based
• Measurable
• Achievable
• Stretching
• Avoid Duplication

• Accreditation
• Wide consultation
• Endorsed by C Exec
• Capacity to monitor
• Annual report
• Communication plan
• Patient feedback
• Implement changes
• Review Date

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Standards for Stroke MCN

• Organisation Management arrangements and
  accountability
• Patient Information, Education and Support
• Multi-disciplinary Working
• Staff Education and Training
• Audit and Monitoring
• Stroke / TIA patient journey

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Long Term Conditions Standards for CHP

• Organisation of long term conditions management
• Patient Information and Supported Self care
• Integrated Multi-disciplinary Working
• Interdisciplinary Education and Training
• Information and Intelligence
• Quality Monitoring

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Continuous Quality Improvement

• Standard
• Rationale
• Criteria
• Mostly qualitative
• Quantitative criteria
• can be mapped across
• from PAF / JPIAF / QOF
• or condition specific audit

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Evaluation

• Annual Self Assessment against standards
• Survey of Patient and Carer Experience
• Summary of the CHPs contribution to the relevant
  fields from the PAF, JPIAF and GMS QO frameworks
• Quality outcomes considered in terms of the
  depcat profile

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Deprivation Categories
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Life Expectancy Contrasts
Glasgow 68.4 years (Male)
Glasgow
Three Rivers, Herts. Female 83.0y
Herts 83years (Female)
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Wider Determinants of Health
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Mind the Gap !
LTC