Framework for managing long term conditions

1. Framework for managing long term conditions The Plymouth PCT commissioning approach

2. Plymouth approach • Accept that long term conditions is a huge subject – almost unmanageable • It cuts across emergency and elective care • Impacts on nearly all of our targets – not just those particularly aligned to LTC • Providers are all contributing to services for LTC but they didn’t always see it.

3. Plymouth approach

4. Two streams of work needed • Generic provision • Bespoke provision

5. Generic • What services are needed irrespective of the disease? • Prevention and public health messages • Diagnostic access • A commitment to providing information and support for people about the disease • A consistent approach for patient and family empowerment, and a self help philosophy

6. Generic ….. • Medication management • Intermediate care • Integrated community services • Single assessment process • Crisis care planning • Care co-ordination • End of life care • Information and performance indicators

7. Bespoke services • Specialist services which understood the specific disease needs and pathway, but work in conjunction with generic services. • Education and support for people around the actual disease. • Work and activities of daily living support, which understood the impact of the illness. • Specialist services working together in instances of co-morbidity.

8. Pathway redesign work • Before embarking on changing any pathway need to have evidence of the following • Understand our local prevalence • Have listened to what our users think of our service and current provision and what they would actually want • Have a picture of local service provision and advances in technology expected in the future

9. What will I be looking for in changed pathways? • Disease prevention measures where possible. • Diagnostics process including support for the person and their family. • Stabilisation and optimisation (links with work, leisure etc) • Education and information including self help strategies.

10. Continued…. • Medication management • Crisis management • Information sharing • Co- morbidity links • End of life care

11. How did we decide on priorities? • Able to demonstrate that the service improvement already occurring supported LTC management. • Considered cost, numbers, appetite for change, ability to influence and opportunities. • Aligned this with strategic objectives and national priorities which could help our cause e.g. 18 weeks targets. • Currently using the NHS institute to help.

12. Evidence of improving outcomes • Stroke Association management of patient information • Unique model of care for community matrons in Plymouth. • MS pathway work, clear understanding of need before looking at pathway, leading to change in priorities. • Development of community cardiac options and expansion in cardiac rehabilitation. • MND network development

13. In summary…. • This type of approach allows commissioners to helicopter across all providers and discourage the creation of lots of ad hoc service provision. • It enables commissioners to really think about shifting money across the services (and achieve it). • For us it helps to makes sense of a massive agenda.