Long Term Conditions

1
Long Term Conditions

• Gail Lett
• Commissioning and Service Development Lead for
  Long Term Conditions Projects

June 2008
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• Background
• Up to 75 of people over 75 years likely to
  suffer from Chronic Illness - 45 have more than
  one condition
• Estimated 80 of GP consultations relate to LTCs.
  A quarter of these are for minor ailments
• LTC care accounts for 60 of bed delays in
  hospitals
• By 2030, incidence of long-term conditions in the
  over 65s is estimated to more than double

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The LTC Model
Case Management
Care / Disease Management
Self Care
Prevention
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Case Management Aim To proactively co-ordinate
the health and social care of people with
multiple long term conditions who are at risk of
deteriorating health in an effort to improve
quality of life, avoid unplanned hospital
admissions or longer lengths of inpatient
episodes.
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Patient Profile

• Aged 18years and registered with a GP
• within HMR PCT plus 3 of the following criteria
• 2 or more active long term conditions
• 4 or more medicines
• 2 or more hospital admissions in the last 12
  months
• 2 or more AE attendances in the last 12 months
• 4 or more GP contacts in last 6 months
• Complex social needs

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Services Offered

• Full assessment of patients health and social
  needs
• Co-ordination of health and social care
• Close and regular liaison with patients GP and
  other professionals involved in patients care.
• Referrals as socially / clinically indicated
• Advanced practitioners provide acute advanced
  clinical and social assessments

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Services offered (continued)

• Co-ordinate and facilitate medication
• Advanced nursing support for residents and staff
  in care homes
• Ongoing monitoring of health and social care
  needs
• Liaison / support of acute colleagues re
  discharge of patients

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Step down / discharge

• Primary objective To enable patients to self
  manage as far as possible.
• Accepted initially for 12 weeks
• When no further interventions required patients
  referred back to primary care
• Beyond 12 weeks reviewed according to clinical
  need.

9

• Disease Management key areas
• Coronary Heart Disease
• Cardiovascular Risk
• COPD
• Diabetes

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• COPD
• Respiratory disease causes 20 of all deaths and
  25 of hospital admissions.
• 75 of respiratory disease deaths are in people
  over retirement age.

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COPD Issues

• Only 1.76 of estimated 5.11 identified
• Experiencing increased unplanned hospital
  admissions
• Lack of early intervention
• Lack of structured care management
• Current services will not meet anticipated future
  demand
• Emergency admissions 2006 / 07 cost 1,517,079

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Proposed Community COPD Service

• Aims
• Support early identification of at risk patients
• Provide proactive quality care to patients
• Provide accurate advice information and education
• Triage referrals to secondary care
• Ensure early identification of risk re potential
  hospital admission

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• Reduce overall length of stay through early
  supported discharge where clinically
  appropriate
• Improve patient experience
• Reduce morbidity and mortality
• Promote and support a joint approach between
  primary, community and secondary care teams

14
Diabetes

• Consistently increasing numbers of people being
  diagnosed
• Obesity trends compounding issue
• Biggest cause of kidney failure, the leading
  cause of blindness in adults of working age and
  one of the biggest causes of limb amputation.
• Significantly increases the risk of coronary
  disease and stroke.

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Diabetes
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Issues

• Screening of at risk groups needs to be
  systematic and targetted at those at greatest
  risk e.g. BME communities
• Current model will not meet future demand
• Wide variation in provision of care

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Recent Developments

• Expansion of the local diabetic retinopathy
  screening service
• Proposal for comprehensive foot care pathway

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Self Care

• Expert Patient Programme
• Diabetes structured education
• Type 2 diabetes - Taking Control
• Type 1 diabetes DAFNE
• COPD Pulmonary Rehabilitation
• Psychological support bid

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Prevention

• Smoking Cessation Services
• Targeted Weight Management Programme
• MEND
• 5 a day programme
• Healthy Walks Programme

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• Assistive Technology
• Joint Assistive Technology Strategy Group
  established.
• Links with Telecare
• Initial funding identified (non-recurrent)
• Pilot through case management service
• User involvement
• Plans into action