Southend on sea PCT

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Southend on sea PCT

• Nurse-led Long term Conditions Management

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60 of adults in England report a chronic health
problem
Out of 59m population

• Diabetes Mellitus affects 1.3m people
• Asthma affects 3.7m adults and 1.5m children
• Arthritis affects about 8.5m in UK
• 74 of those with long term medical condition in
  the UK have 1 or 2 problems 26 have 3 or more
  problems
• 8.8m people in England have a long term illness
  that severely limits their day to day ability to
  cope.

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LTC Principles

• NHS and Social Care Long Term Conditions Model
• for the individual self care is key
• for the service its organisation
• Key elements include
• whole system delivery
• matching resources to need
• Unique opportunity to be systematic and personal
  by working together collaboratively

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LTC Management
Population-wide Prevention
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LTC key components of care

• Population Management
• Effective registers and integrated records
• Evidence based care pathways
• Disease management and care co-ordination
• Self care/self management with information and
  support
• Active management of at risk patients
• Primary/secondary/social care co-ordination

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LTC and Self Care
Case management
Level 3
Highly complex patients
Disease management
Level 2
Professional care
High risk patients
Self care
Self care
Level 1
70-80 of an LTC population
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Themes for the future workforce

• Case management
• Moving services into the community
• Enabling and supporting patient/professional
  partnership
• Integrated, multi-disciplinary teams across
  health and health and social care

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Community Matrons/Case Manager

• Selection Criteria a Community Matron is an
  experienced highly qualified nurse capable of
  working to an advanced clinical level diagnosing
  and treating complex conditions, working in
  partnership with the service user, all other
  stakeholders and professionals.
• Objectives to optimise health and well-being,
  reduce complications and inappropriate hospital
  admissions through a whole systems approach to
  care.

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Long Term Conditions Community Matrons 2005-6

• Alan Sobratty RGN RMN DN DipN BSc(Hons)
• Johanna Packer RGN BSc(Hons) DN
• Gillian Judge RGN BSc (Hons) DN RM
• All studying for MSc in Advanced Clinical
  Practice all are Extended and Supplementary
  Prescribers.
• 3 Health Care Assistants (NVQ 3) with social care
  backgrounds (offered Associate Practitioner (NVQ
  4).

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Case management a definition

• A collaborative process which assesses, plans,
  implements, co-ordinates, monitors and evaluates
  the options and services required to meet an
  individuals health, care, educational and
  employment needs, using communication and
  available resources to promote quality cost
  effective outcomes.
• Case Management Society UK 2005

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Case Management the role

• To enhance the quality of life for
  clients/service users while potentially reducing
  the overall cost of disability.
• To collaborate with service users/clients by
  assessing facilitating, planning and advocating
  for health and social needs on an individual
  basis
• Effective case management will directly and
  positively affect the social, ethical and
  financial health of the country and its
  population.
• Case Management Society 2005

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Case Managers- may be selected from any
health or social care professional background but
may not be able to personally provide for some of
the advanced clinical needs of the service user
but will function in a multiprofessional/multiagen
cy team where these needs can be met. The service
user will be managed by the professional who can
meet the majority of their needs be they social
or health and refer to team members for other
aspects of care.
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Strategic Health Authority Trajectories

• Year VHIUs Community Case Managers
• Matrons
• 60 0 0
• 121 1.9 2.3
• 332 7.5 4.6
• 604 7.5 4.6

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Referral criteria

• Adults who have two or more long term conditions
  including
• Chronic Obstructive Pulmonary Disease
• Coronary Heart Disease
• Diabetes
• A history of Falls
• and/or multiple admissions to hospital
• service extending in 2006 to neurological
  conditions e.g. Multiple Sclerosis, Motor Neurone
  Disease, Muscular Dystrophy etc

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Referral route

• Open access from all health and social care
  professionals
• Patient identification/case finding via PARR
  algorithm hospital discharge process and
  retrospective analysis of hospital admissions by
  GP and through disease registers.