New Horizons. Long Term Conditions

Transcription

1 New Horizons Long Term Conditions

2 Years of this

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4 : The Legacy

5 Rising at all ages People reporting a chronic condition (by age) % of sample y 5-15y 16-44y 45-64y 65-74y Year (note: data from1998 is w eighted)

6 Implications of aging population More likely to live alone More likely to have functional dependency and sensory impairment More likely to have long term condition More likely to have co-morbidity More likely to have cognitive impairment

7 More likely to have multiple medications More likely to develop complications of acute illness More likely to develop infection More likely to stay longer in hospital More likely to require rehabilitation

8 Long Term Condition Condition that requires ongoing medical care, limits what one can do, and is likely to last longer than one year. NHS Scotland 2005

9 Healthcare Burden of LTCs People with LTCs contribute. 80% of all GP consultations 60% of all inpatient bed days 70% of all emergency admissions 80% of all prescribed medicines 50% of people with LTCs do not take prescribed medications Economic and Social aspect Impacts on whole system

10 By 2030 incidence of LTCs in the over 65s will have doubled

11 Key points. 5% of people occupying acute hospital beds accounted for 43% of bed days Most deprived are twice as likely to be admitted than least deprived People in the high use group have multiple diagnoses ( four or more)

12 An example. Heart failure Expected to rise by 40% over the next 20 years Diabetes 1.3 million with another million undiagnosed Peripheral vascular disease 4.5% of people between show signs of PVD Respiratory disease COPD 600,000 Asthma 3.7 million adults & 1.5 million children

13 Current systems Lack of information Need continuity Medical model still exists System is not seamless Too many hand offs Inequity of care Lack of co-ordination Poor communication Change is essential People lost during transitions

14 Other concerns Carers issues Transition from child services to adult care and older adult Non-adherence / concordance Impact on family

15 LTCs - Was the organisation ready? Self Assessment Tool kit (SGHD) Long Term Conditions Action Team Organisation of Long Term Conditions CHPs Responsibility Board & Management Support Links with right people / agencies / organisations Shared objectives (Primary & Secondary Care) Links with & informed Community Planning

16 Standards.. Patient Information & supported self care Service redesign - must include LTC Multi-agency working Interdisciplinary education and training Information and Intelligence Quality and Delivery Set up Long Term Conditions Action Team

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19 Long Term Conditions Collaborative Collaborative methodology LTCAT = LTCC Programme Board Wide stakeholder membership National and Regional Team National Improvement Measures 4 Workstreams

20 Self Management Diabetes COPD Pain Stroke Generic Exercise Project Self Held Care Plans Directory of Services Carer support & training Clinician support & training

21 COPD Self Management First Hand Experience

22 Condition Management MCNs Clinical pathways CSIGs Clinical & Service Models Optimising roles Clinical support & training Carer support & training Neurology

23 Complex Care Integrated Care Management Care Homes Support Palliative Care (malignant & non malignant) Anticipatory Care Plans Community Hospitals

24 Information & Evaluation National improvement measures Local improvement measures Logic Model approach

25 LTCCP & New Horizons LTCCP improvement actions/developments New Horizons actions/deliverables