long term conditions presentation
TRANSCRIPT
Long Term ConditionsPresentation
CHP Committee3rd September 2007
Aims
♦Provide CHP with overview of national,regional and local long term conditions(LTC) agenda.
♦Provide CHP with an overview of thecompleted Angus CHP Self AssessmentToolkit
♦Seek approval of LTC Action Plan
Long Term Conditions (LTC) :Background
National, Regional and Local
Long Term Conditions
♦Defined by WHO as the healthcarechallenge of this century.
♦Consumes 78% of all NHS resources♦ 1 in 3 suffering from a LTC♦ 15% suffer from 2 or more coexistent
diseases♦National and regional priority
Delivering for Health
Need to enable people with LTC to livehealthy lives through:
♦ Increasing support for self-care♦Anticipating needs of vulnerable people♦ Identifying those at greatest risk of hospital
admission and providing them with earliercare to prevent deterioration of health andreduce emergency admissions
Hierarchy of CareLevel Three High ComplexityCase Management
Level Two High RiskDisease/Care Management
Level One Supported SelfCare
70-80% of LTC Population
Chronic Obstructive AirwaysDisease (COPD) in Angus
Previous Issues in Angus:♦ > Burden of disease♦ Lack of training♦ Lack of access to pulmonary
rehabilitation♦ Absence of pathway of care
for patients with COPD♦ < opportunity for supported
self-care
Respiratory Developments
Annual Review (GMS)Pulmonary Rehabilitation,COPD Housebound ServiceESD/POA
Patient Self Help
EducationEquipment
CommunicationNationalevidence
Outcomes♦ < Hospital admissions for COPD patients
following pulmonary rehabilitation (27 to 1 bedday post rehabilitation).
♦ Clinical improvements in patients followingpulmonary rehabilitation e.g. breathlessness,shuttle walk, anxiety levels and depression.
♦ > Patient satisfaction with both pulmonaryrehabilitation and COPD housebound service andreported improvements in condition
♦ All Angus practices now have staff trained todiploma level in COPD and asthma.
Regional LTC Planning♦Action plan across partnerships♦Case management pilots Dundee & Perth &
Kinross.♦Complex case study in Angus♦Self Management Framework♦Collaborative Commissioning Promises♦Big Lottery Fund Bid♦Host National Improvement Programme
Self-Assessment Tool♦Scottish Executive tool♦Aims to support systematic approaches to
the provision of LTC services as close tohome as possible, supporting Shifting theBalance of Care.
♦Generic♦Multi-agency♦ Identify areas of good practice and areas for
development
2007 Results?
13306. Quality & delivery
18245. Information and Intelligence
21244. Interdisciplinary education
16243. Service design and multi-agency working
13242. Patient Information & Supported Self-Care
20241. Organisation
Sub-Total2007
Max.Value
Standard
LTC Action Plan : Key Themes
♦Communication/Planning♦Patient information♦Carers♦Supporting Self-Care♦Condition Specific Care♦ IT
Supporting Self-Care
♦Self-held care plans♦Staff training e.g. motivational awareness &
behaviour change training♦Generic patient led self-management
programmes♦Peer support groups