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