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Framework for managing long term conditions

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Framework for managing long term conditions The Plymouth PCT commissioning approach Plymouth approach Accept that long term conditions is a huge subject almost ... – PowerPoint PPT presentation

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Title: Framework for managing long term conditions


1
Framework for managing long term conditions
  • The Plymouth PCT commissioning approach

2
Plymouth approach
  • Accept that long term conditions is a huge
    subject almost unmanageable
  • It cuts across emergency and elective care
  • Impacts on nearly all of our targets not just
    those particularly aligned to LTC
  • Providers are all contributing to services for
    LTC but they didnt always see it.

3
Plymouth approach
4
Two streams of work needed
  • Generic provision
  • Bespoke provision

5
Generic
  • What services are needed irrespective of the
    disease?
  • Prevention and public health messages
  • Diagnostic access
  • A commitment to providing information and support
    for people about the disease
  • A consistent approach for patient and family
    empowerment, and a self help philosophy

6
Generic ..
  • Medication management
  • Intermediate care
  • Integrated community services
  • Single assessment process
  • Crisis care planning
  • Care co-ordination
  • End of life care
  • Information and performance indicators

7
Bespoke services
  • Specialist services which understood the specific
    disease needs and pathway, but work in
    conjunction with generic services.
  • Education and support for people around the
    actual disease.
  • Work and activities of daily living support,
    which understood the impact of the illness.
  • Specialist services working together in instances
    of co-morbidity.

8
Pathway redesign work
  • Before embarking on changing any pathway need to
    have evidence of the following
  • Understand our local prevalence
  • Have listened to what our users think of our
    service and current provision and what they would
    actually want
  • Have a picture of local service provision and
    advances in technology expected in the future

9
What will I be looking for in changed pathways?
  • Disease prevention measures where possible.
  • Diagnostics process including support for the
    person and their family.
  • Stabilisation and optimisation (links with work,
    leisure etc)
  • Education and information including self help
    strategies.

10
Continued.
  • Medication management
  • Crisis management
  • Information sharing
  • Co- morbidity links
  • End of life care

11
How did we decide on priorities?
  • Able to demonstrate that the service improvement
    already occurring supported LTC management.
  • Considered cost, numbers, appetite for change,
    ability to influence and opportunities.
  • Aligned this with strategic objectives and
    national priorities which could help our cause
    e.g. 18 weeks targets.
  • Currently using the NHS institute to help.

12
Evidence of improving outcomes
  • Stroke Association management of patient
    information
  • Unique model of care for community matrons in
    Plymouth.
  • MS pathway work, clear understanding of need
    before looking at pathway, leading to change in
    priorities.
  • Development of community cardiac options and
    expansion in cardiac rehabilitation.
  • MND network development

13
In summary.
  • This type of approach allows commissioners to
    helicopter across all providers and discourage
    the creation of lots of ad hoc service provision.
  • It enables commissioners to really think about
    shifting money across the services (and achieve
    it).
  • For us it helps to makes sense of a massive
    agenda.
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