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Prevention and Management of Long Term Conditions
Co-Production Workshop 23rd October 2019
Emily Byway Project Manager
www.enhertsccg.nhs.uk
Prevention and Management of Long Term Conditions Co-Production - - PowerPoint PPT Presentation
Prevention and Management of Long Term Conditions Co-Production - - PowerPoint PPT Presentation
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,
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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
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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.”
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Appointments
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Have we over complicated it?
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Models of Care
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STP Vision
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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
Prevalence
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The Strategy
Prevention Identification and Diagnosis Proactive Management End of Life Care Workforce Development
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Delivering the Strategy
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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.
Prevention
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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.
Prevention
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- 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
- ffered 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
Prevention
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- 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
Identification and Diagnosis
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- 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.
Proactive Management
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- 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.
Proactive Management
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- 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.
Proactive Management
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- 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.
Proactive Management
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- 37. All LTC pathways should include identifying when someone is