Prevention and Management of Long Term Conditions Co-Production Workshop 23 rd October 2019 Emily Byway Project Manager www.enhertsccg.nhs.uk .
Long Term Conditions NHS Long Term Plan “A new service model in which patients get more options, better support, and proper joined-up care at the right time in the right optimal care setting” Specialist / disease specific services – delivering high standards in their specific area However, 15% of people in East and North Herts have more than one LTC. Cannot keep working in disease specific silos Providers and commissioners cannot work in isolation if we are to improve services for people with Long Term Conditions. www.enhertsccg.nhs.uk
Patient Feedback Delays in system - Initial assessment -> Treatment -> Ongoing Support Develop second condition – start the cycle again Better communication with patients and other professionals Clear information – can be contradicting if patient has multiple conditions No options - Over 70 – “it’s your age” Don’t feel listened to www.enhertsccg.nhs.uk
Patient Feedback “Access to medics now so v complicated. No public transport, visits to surgery cost £13 return by taxi, husband and I just feel totally isolated, old (70 & 80) and just exist from day to day.” www.enhertsccg.nhs.uk
Appointments www.enhertsccg.nhs.uk
Have we over complicated it? www.enhertsccg.nhs.uk
Models of Care www.enhertsccg.nhs.uk
STP Vision www.enhertsccg.nhs.uk
Prevalence Prevalence Register England Respiratory Chronic Obstructive Pulmonary Disease 1.57 9,386 1.91 Asthma 5.82 34,798 5.93 Cardiovascular Atrial Fibrillation 1.85 11,046 1.91 Cardiovascular Disease 1.21 4,046 1.14 Heart Failure 0.64 3,806 0.83 Hypertension 13.40 80,121 13.94 Stroke 1.66 9,905 1.77 Endocrine Chronic Kidney Disease 3.02 14,229 4.11 Diabetes 5.88 28,073 6.79 Neurological Dementia 0.73 4,343 0.76 Epilepsy 0.75 3,528 0.80 MSK Osteoprosis (aged 50+) 0.48 1,034 0.62 Rheumatoid Arthritis (16+) 0.71 3,428 0.75 www.enhertsccg.nhs.uk
www.enhertsccg.nhs.uk
The Strategy Prevention Identification and Diagnosis Proactive Management End of Life Care Workforce Development www.enhertsccg.nhs.uk
Delivering the Strategy www.enhertsccg.nhs.uk
www.enhertsccg.nhs.uk
Prevention 1. Ensure that health care professionals across the CCG work with Public Health Hertfordshire to address the social determinants of health and reflect this in patient care. 2. Primary Care Networks to apply population health management to their local areas to improve health outcomes and reduce health inequalities. 3. Record weight, height, BMI, BP, Smoking Status and Physical activity status for every patient to support the CCG in understanding the prevalence 4. Ensure all pathways reflect opportunities to refer or signpost to weight management services, smoking cessation services and physical activities. 5. Ensure local policies are in place which encourages patients to lose weight, stop smoking and get active such as fitness for surgery. www.enhertsccg.nhs.uk
Prevention 6. Ensure health care providers have access to the latest information and guidance regarding healthy weight, smoking advice, physical activity guidelines and support services. 7. Ensure patients are offered support to address their weight, stop smoking or be more physically active either through commissioned services or signposting to community programmes. Information and support on such services accessible to all. 8. Promote healthy sleep habits as part of healthy living – alongside diet and exercise 9. Health checks and annual reviews to include questions relating to sleep patterns, pain and pain management 10. Patients with multiple risk factors should be treated holistically rather than by risk factor. www.enhertsccg.nhs.uk
Prevention 11. All patients with a CVD risk score greater than 10% and/or with a long term condition to be offered smoking cessation advice, treatment and referral to stop smoking services and recorded in the patient records. 12. Patients who are unwilling to stop smoking should be encouraged to consider electronic cigarettes (Vaping) as an alternative. 13. Ensure that brief advice provided to patients identified as a smoker in secondary care includes onward referral to stop smoking services and is documented within the discharge summary. Follow up with these patients post discharge to ensure smoking cessation support has been offered and referral made. 14. Charter House to become a smoke free zone and encourage providers/ stakeholder to adopt same policy. E.g. local authority, primary care settings, acute settings www.enhertsccg.nhs.uk
Identification and Diagnosis 15. Reduce the number of “undetected LTCs” by ensuring correct coding and diagnosis 16. Promote risk stratification to identify patients at risk of developing a long term conditions 17. Increase the proportion of patients with SMI receiving a physical health check 18. A clear comms campaign tackling awareness, preventing, living with and end of life for LTCs 19. Clear sources of support for newly diagnosed patients 20. Pathways to include signposting to MH support following diagnosis www.enhertsccg.nhs.uk
Proactive Management 21. Central point of information for all long term conditions accessible to patients, carers and health care professionals to ensure consistent messaging 22. Information should not only be in paper/online formats. Identify peer support networks for people to learn from those in a similar position. 23. Review the education and support accessible to people with long term conditions and identify gaps in current pathways. 24. A rolling education programme relating to living with and managing long term conditions should be accessible to all individuals, carers and families, relate to “real life” situations and promoted throughout the year. www.enhertsccg.nhs.uk
Proactive Management 25. Patient activation levels to be monitored as part of their annual review 26. Use community-based interventions and social prescribing to support people to manage their condition / prevent development of LTCs – live well 27. Everyone with a long term condition to be offered a care plan that captures what is important to the patient and their goals = to be recognisable in all health and social care settings. 28. Increase the use of digital technology to help individuals self-manage their conditions. 29. Shared decision making to be embedded into all pathways and tools used to support this where available e.g. NHS decision aides. www.enhertsccg.nhs.uk
Proactive Management 30. Patients to have a clear understanding of what is involved in an annual review and who will undertake this e.g. consultant or GP 31. Additional appointment time to be given to patients with multiple LTCs to ensure a full and comprehensive review takes place 32. Patients to be encouraged to be an active participant in their review e.g asked to consider what is important to them and their goals prior to attending 33. Implement a recall system based on patient birth month so that patients know when they are due to have their annual review and services can manage demand. 34. Medicines management advice for patients with multiple long term conditions needs to be tailored to the individual, clear and easily accessible. www.enhertsccg.nhs.uk
Proactive Management 35. Outpatient transformation Central appointment system - one contact re: booking and cancelling – that looks at all requirements the patient has e.g. if needing 2 outpatient appointments with different consultants, ability to book both on same day. 36. A structured tier approach to supporting people with LTCs and their mental health from Tier 1 – low level awareness to more structured specialist support specifically relating to the patients long term condition. www.enhertsccg.nhs.uk
Palliative and End of life care 37. All LTC pathways should include identifying when someone is reaching the end of life stage and ensuring that the appropriate support is provided. www.enhertsccg.nhs.uk
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