The Broad Picture - recent developments in long-term condition managment
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The document outlines recent developments in long-term condition management in Scotland, emphasizing a strategic direction that focuses on multidisciplinary and holistic care, patient involvement, and self-management. It critiques the current hospital-centered model and advocates for a shift towards community-based, integrated care that involves using technology and systematic approaches to cater to the needs of patients. Key aims include reducing health inequalities, improving the quality of care, and enabling individuals to manage their conditions more effectively.
The Broad Picture - recent developments in long-term condition managment
- 1. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT DR AILEEN KEEL DEPUTY CHIEF MEDICAL OFFICER May 2007
- 2. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Strategic Direction CMO Workstream Long Term Conditions Alliance Scotland Self Care CHP Toolkit SPARRA/Integrated Care Managed Clinical Networks Related Policies
- 3. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Strategic Direction (1) Key to managing long-term conditions (Kerr Report) Multidisciplinary team holistic care Patient involvement self care 1 ° care coordinated care in least intensive setting hospital visits/admissions Integrate 1°/2° care and health/social care Population approach 1° care register of LTC patients Use of IT/evidence based protocols/better medicines management Use of voluntary sector/support for family carers
- 4. Tackling Health Inequalities Shifting the Balance of Care Long Term Conditions Diagnostics Planned Care Unscheduled Care eHealth Rural Health Care Mental Health Child and Maternal Health Tertiary Paediatric Care Neurosciences THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Strategic Direction (2)
- 5. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Strategic Direction (3) Current Model of Care Geared towards acute conditions Hospital centred Doctor dependent Episodic care Disjointed care Reactive care Patient as passive recipient Self care infrequent Carers undervalued Low tech Evolving Model of Care Geared towards long-term conditions Embedded in communities Team based Continuous care Integrated care Preventive care Patient as partner Self care encouraged and facilitated Carers supported as partners High Tech
- 6. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Strategic Direction (4) – Systematic Approach More effective matching of patient’s needs to level of response Holistic approach to patient’s needs when they have more than one condition Use of IT to deliver joined up care Use the skills of the whole clinical team more effectively Develop systematic contact and support for patient self care Reduce emergency admissions Ensure consistency of approach and dissemination of best practice
- 7. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Strategic Direction (5)
- 8. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT CMO Workstream (1) National Strategy (Delivering for Health): Steering Group: NHS and Long-Term Conditions Alliance Scotland (LTCAS) Open Space events and report “ People’s experiences of being with or caring for someone with long-term conditions must be central to how services are designed and delivered.”
- 9. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT CMO Workstream (2)
- 10. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Long Term Conditions Alliance Scotland Established 2006 A national voice to ensure the interests and needs of people living with long term conditions are heard and addressed 4 overarching aims: Influencing and campaigning Supporting and improving practice Supporting the voluntary and community long term condition sector Tackling health inequalities
- 11. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Self Care (1) Allows people living with long term conditions to achieve and maintain optimum wellbeing LTCAS ‘Gaun Yersel’ conference November 2006 Supported Self-Care in Cancer Programme LTCAS Sub-Group Departmental secondee
- 12. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Self Care (2) (LTCAS report) Self-management programmes should include: Relevant information Information about benefits of diet and exercise Coping techniques and pain management strategies Peer support, to make it easier to accept the ‘gaun yersel’ message Outcomes of self-management: Increased effectiveness of medical treatment Helps people manage their condition properly Improves health and reduces pain, fatigue and depression More efficient use of NHS resources, through e.g. reduction in number of GP visits Improvement in self-confidence levels
- 13. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT CHP Toolkit HDL(2007)10 Mandatory for all 41 CH(C)Ps Standard 3: Service Design and Multi-disciplinary/multi-agency working Criterion 3.3: “CHP has range of services including …… palliative care (taking account of Gold Standards Framework Scotland) ……” Action Plans
- 14. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT SPARRA/Integrated Care S cottish P atients a t R isk of R eadmission and A dmission Risk Reduction Algorithm: identifies patients at high risk of unscheduled hospital admission Assumes intensive case management available to those patients Need to systematise (Workshop 22 May)
- 15. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Managed Clinical Networks (1) Acute Services Review 1998 “ MCNs are linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, uncontained by existing professional boundaries, to ensure equitable provision of high quality, clinically effective services throughout Scotland.” NHS MEL(1999)10: 9 February 1999 NHS HDL(2002)69: 18 September 2002
- 16. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Managed Clinical Networks (2) HDL(2007)21: Strengthening the Role of MCNs Key tool to deliver further transformational change through: Improving service quality and performance management Acting as planning fora for disease areas or topics Examples: CHD, stroke, diabetes, MCNs; respiratory MCNs; palliative care MCNs; chronic pain MCN in Greater Glasgow and Clyde Managed Care Networks
- 17. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Related Policies Joint Futures: single shared assessment Carers’ strategy ‘ Changing Lives’: social work review Visible, Accessible and Integrated Care: review of community nursing ‘ Delivering for Mental Health’ Rehabilitation Framework Joined up Thinking, Joined up Care
- 18. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Summary (1) – Strategy for LTCs Why? Ageing Population Number of people with multiple LTCs complex Disadvantaged communities more LTCs Small number of people with LTCs disproportionate health care deployment (eg ~ 80% GP consultations)
- 19. THE BROAD PICTURE RECENT DEVELOPMENTS IN LONG-TERM CONDITION MANAGEMENT Summary (2) – Strategy for LTCs How? Building on what has gone before - MCNs - CHPs - Kerr - Delivering for Health Strengthening and extending 1 ° care Anticipatory care for vulnerable cases Support for self care