Long Term Conditions Strategy There are 3 key aims to our improvement strategy: WHCCG has already achieved: – Commissioned Diabetes education through the WH Diabetes service that reduced the amount of admissions to hospital for low blood sugar crises by 8% over 3 years and over the same period increased the amount of people with stable blood glucose under 7.5% from 52% to 70%. – Extended early supported discharge for stroke, reducing length of stay – Expanded cardiac and pulmonary rehabilitation services and community health failure nursing support to enable people to – Committed funding for a West Hampshire Wide Enteral Nutrition Service and an integrated respiratory service – There are still, however gaps in specialist community support and in rapid access by GPs to that support We want the residents of West Hampshire to live in an environment that supports their health; to know about and take active steps to improve their health; to have rapid equal access to coordinated care when they need it right up until the end of life. Prevention of long term illness, earlier identification of long term conditions and taking early steps with those at risk Putting in place supported self-care so that people have more control over their health and care Coordinating care from the patient’s point of view Prevention of long term illness, earlier identification of long term conditions and taking early steps with those at risk Putting in place supported self-care so that people have more control over their health and care Coordinating care from the patient’s point of view

Assessment of Need/JSNA ,000 people with Diabetes in WH 9,134 Undiagnosed 7,700 people with COPD in WH 4,043 Undiagnosed prevalence of asthma 6.1% 11,208 stroke patients in WH LTCs make up 40-55% GP appts LTCs account for 60% of Outpatient appts and 70% of inpatient bed days There are 540,000 living in West Hampshire, 144,000 have a long term condition 3,200 on GP epilepsy registers, 1500 people with Parkinson's, 1,094 with MS in WH 10,760 with Undiagnosed heart disease 25% Over 60 + ≥2 LTC 13.7% Growth in >65s in Hants to % Growth in >85s in Hants to 2019 BUT: Emergency Admissions in WH lower than average

5 Year Strategic Intentions Develop and redesign long term conditions diagnosis pathways, using screening and earlier identification of risk Commission prevention programmes for people on GP registers who are at risk of developing long term conditions. Commission services to provide people with appropriate information about their conditions, personalised care plans and active lifestyle programmes to enable them to manage their long term conditions. Ensure co-ordinated care for people with long term conditions with clear lines of communication between those who provide universal care and provide specialist care, along with training of those professionals on key issues such as shared decision making, psychological support, dementia, crisis management and trial approaches to coordinating clinics for different long term conditions. Commission specialist community services in areas where they are not currently provided, moving towards seven day services for all people with long term conditions.

Organisational Processes Engaged informed patient HCP who work as partners Responsive Commissioning Measuring Success: The House of Care Personalised care plans: 100% of people with 2 or more LTCs have a, 75% of those with one LTC % of integrated, primary care and specialist team members trained in shared decision making % of specialist team trained in basic psychological assessment and support % People with diabetes, heart failure, COPD diagnosed less than 6 months referred to structured health literacy and active lifestyles programmes (including cardiac and pulmonary rehab) % Uptake of personal health budgets for people on continuing health care % with patient held records Increase in people feeling supported to manage their own condition A central database between health and social care, saving the time of professionals and people with long term conditions in continually revisiting basic information 10% Reduction in the prevalence gap for each LTC so that people get to know they have a condition earlier Lower emergency admissions Web Published service and condition specific information for people with LTCs and those that support them Specialist nurses available no matter where you live in West Hampshire Increase in GP referrals to community resources Telephone support for carers Reductions in levels of smoking among people with LTCs and those at risk of LTCs Record of the year’s health and significant events at the annual check-up with GP:

Prevention Staying as healthy as possible for as long as possible Potential Help and Care Community based and led smoking cessation, 3rd sector support for healthy lifestyles, community walks and active lifestyle programmes for those at risk, flu vaccinations Soon after diagnosis: an initial management plan, referral to structured education, and active lifestyle support. Regular review of person-centered goals in management plan by GP and practice nurse, Specialist rehab where necessary. Psychological support if you need it Access to “living with” LTC programmes. You plan with your GP now for signs of sudden deterioration; back up support is available by phone from a specialist nurse. Psychological support if needed Regular support (includes psychological) from local teams & specialist nurses, back up from hospital & ambulance teams that know the advanced plan. Supported recovery from crisis, that involves the community teams and specialist nursing. Hospital admission with supported discharge You are a member of the general public and may live in an area where a lot of people have long term conditions You have a long term condition but do not yet know it You know that have at least one long term conditions You are experiencing mild to moderate symptoms from one/multiple conditions Your symptoms keep you home most of the time You are experiencing a flare-up of symptoms You are critically unwell Crisis management End of Life Care Knowing your condition, warning signs and what to do Implement advanced plan with integrated team Phases Priorities are: Long Term Conditions Pathway: What Good Looks Like