Long Term Conditions what is the emerging model of care what will be the issues/implications arising from this what are the resource, IM&T, workforce, capital issues arising what are the links/dependencies to other workstreams what are the risks associated with the work what are the next steps?

What is the emerging model of care ? Case Management Pathway Development Self Care – Managed Care – Acute Care Assessment, Diagnosis, intervention Roles and Responsibilities Health and Social Care Primary and Secondary Care

What will be the issues and/or implications arising from this model Matrix modelling Who is doing what When they are doing it What they are doing Move to ‘joined up’ service not care in ‘Silos’ Workforce Redesign Referral processes

What are the resource, IM&T, workforce, capital issues arising ? Role Redesign What roles need to be changed? Education and training issues Information Exchange Technology Systems Consent Confidentiality Estate Infrastructure Resource Centres Walk in centres

What are the links/dependencies to other workstreams? Common Themes Assessment Diagnosis Intervention Common Generic Pathway Care management form one care setting to another Element of Self Care

What are the risks associated with the work? Professional Tribalism Silo workstreams not joined up Buildings dictate the service model not the needs of the patient. Management of Change Professional and Organisational boundaries Not enough money

Agree the common aspects of the workstream What are the next steps? Agree the common aspects of the workstream Self Care HR issues Education and training Role redesign Agree on project plan and get sign up across health and social care organisations