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Community Transformation & Long Term Conditions Dominic Blaydon & Sarah Whittle What is a Long Term Condition “Long-term conditions are those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered. There is no return to ‘normal’.” Department of Health Types of Long Term Condition Hypertension 81,144 Cardio Vascular Disease 17,980 Diabetes 15,486 Chronic Obstructive Pulmonary Disease 8,784 Stroke 6,595 Parkinson’s Disease 4,637 Multiple Sclerosis 3,606 Coronary Heart Failure 1,587 Impact on local health economy • 70% of health & social care spend • 80% of in-patient bed days • 55% of GP appointments • 70% of outpatient and A&E attendances What do people with LTCs need? 8 issues that impact on experience of health and care services: • Fast access to reliable health advice • Effective treatment delivered by trusted professionals • Involvement in decisions and respect for preferences • Clear, comprehensible information and support for self-care • Attention to physical and environmental needs • Emotional support, empathy and respect • Involvement of, and support for, family and carers • Continuity of care and smooth transitions How to improve services • Risk stratification • Case management – Single budget and manager • Single point of access • Patient skills programmes – Self management • Psychological support • Practitioner skills programmes • Effective joint governance arrangements • Aligned incentives - through new financial models • Data sharing with real time access Social Prescribing – What is it? • Social prescribing is a framework for linking patients with non-medical needs affecting their health, wellbeing and ability to self-manage, to sources of support within the community. What are we doing? • Introduction of a risk stratification tool • Case management programme • Social prescribing • 3rd sector engagement on supporting people with LTCs • Reconfiguration of community nursing services • Utilisation of alternative levels of care • An enhanced Care Coordination Centre • Integrated pathways across health/social care and acute/community • Better performance management of community health services Any Questions?
