New Horizons Long Term Conditions
Years of this
2000 2050: The Legacy
Rising at all ages People reporting a chronic condition (by age) 80 70 % of sample 60 50 40 30 0-4y 5-15y 16-44y 45-64y 65-74y 75+ 20 10 0 1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002 Year (note: data from1998 is w eighted)
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
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
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
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
By 2030 incidence of LTCs in the over 65s will have doubled
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)
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 55 74 show signs of PVD Respiratory disease COPD 600,000 Asthma 3.7 million adults & 1.5 million children
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
Other concerns Carers issues Transition from child services to adult care and older adult Non-adherence / concordance Impact on family
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
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
Long Term Conditions Collaborative Collaborative methodology LTCAT = LTCC Programme Board Wide stakeholder membership National and Regional Team National Improvement Measures 4 Workstreams
Self Management Diabetes COPD Pain Stroke Generic Exercise Project Self Held Care Plans Directory of Services Carer support & training Clinician support & training
COPD Self Management First Hand Experience
Condition Management MCNs Clinical pathways CSIGs Clinical & Service Models Optimising roles Clinical support & training Carer support & training Neurology
Complex Care Integrated Care Management Care Homes Support Palliative Care (malignant & non malignant) Anticipatory Care Plans Community Hospitals
Information & Evaluation National improvement measures Local improvement measures Logic Model approach
LTCCP & New Horizons LTCCP improvement actions/developments New Horizons actions/deliverables