1. Nurse-led Long term Conditions Management
Southend on sea PCT
Nurse-led Long term Conditions Management

2. 60% of adults in England report a chronic health problem
Out of 59m population:
Diabetes Mellitus affects 1.3m people
Asthma affects 3.7m adults and 1.5m children
Arthritis affects about 8.5m in UK
74% of those with long term medical condition in the UK have 1 or 2 problems; 26% have 3 or more problems
8.8m people in England have a long term illness that severely limits their day to day ability to cope.

5. Infrastructure Delivery System Better outcomes
Health and social system environment
Decision support tools and clinical information system (NPfIT)
Community Resources
Delivery System
Disease Management
Case Management
Better outcomes
Prepared and proactive health and social care teams
Empowered and informed patients
Supported
Self care
Promoting Better Health
Supporting
Creating
The NHS and Social Care
Long Term Conditions Model

6. LTC Principles NHS and Social Care Long Term Conditions Model
for the individual self care is key
for the service its organisation
Key elements include:
whole system delivery
matching resources to need
Unique opportunity to be systematic and personal by working together collaboratively

7. Population-wide Prevention
LTC Management
Level 3
Highly complex patients
Case
Mgt
Disease
Management
Level 2
High risk patients
Self
Management
Level 1
70-80% of an LTC population
Population-wide Prevention

8. LTC – key components of care
Population Management
Effective registers and integrated records
Evidence based ‘care pathways’
Disease management and care co-ordination
Self care/self management – with information and support
Active management of at risk patients
Primary/secondary/social care co-ordination

9. LTC and Self Care Level 3 Level 2 Level 1 Case management
Highly complex patients
Disease management
Professional care
Level 2
High risk patients
Self care
Self care
Level 1
70-80% of an LTC population

10. Themes for the future workforce
Case management
Moving services into the community
Enabling and supporting – patient/professional partnership
Integrated, multi-disciplinary teams across health and health and social care

11. Community Matrons/Case Manager
Selection Criteria – a Community Matron is an experienced highly qualified nurse capable of working to an advanced clinical level diagnosing and treating complex conditions, working in partnership with the service user, all other stakeholders and professionals.
Objectives – to optimise health and well-being, reduce complications and inappropriate hospital admissions through a whole systems approach to care.

12. Long Term Conditions Community Matrons 2005-6
Alan Sobratty RGN RMN DN DipN BSc(Hons)
Johanna Packer RGN BSc(Hons) DN
Gillian Judge RGN BSc (Hons) DN RM
All studying for MSc in Advanced Clinical Practice all are Extended and Supplementary Prescribers.
3 Health Care Assistants (NVQ 3) with social care backgrounds (offered Associate Practitioner (NVQ 4).

13. Case management – a definition
‘A collaborative process which assesses, plans, implements, co-ordinates, monitors and evaluates the options and services required to meet an individuals health, care, educational and employment needs, using communication and available resources to promote quality cost effective outcomes’.
Case Management Society UK 2005

14. Case Management – the role
To enhance the quality of life for clients/service users while potentially reducing the overall cost of disability.
To collaborate with service users/clients by assessing facilitating, planning and advocating for health and social needs on an individual basis
Effective case management will directly and positively affect the social, ethical and financial health of the country and its population.
Case Management Society 2005

15. Case Managers - may be selected from any health or social care professional background but may not be able to personally provide for some of the advanced clinical needs of the service user but will function in a multiprofessional/multiagency team where these needs can be met. The service user will be managed by the professional who can meet the majority of their needs be they social or health and refer to team members for other aspects of care.

16. Strategic Health Authority Trajectories
Year VHIUs Community Case Managers
Matrons

17. Referral criteria
Adults who have two or more long term conditions including
Chronic Obstructive Pulmonary Disease
Coronary Heart Disease
Diabetes
A history of Falls
and/or multiple admissions to hospital
service extending in 2006 to neurological conditions e.g. Multiple Sclerosis, Motor Neurone Disease, Muscular Dystrophy etc

18. Referral route
Open access from all health and social care professionals
Patient identification/case finding via PARR algorithm – hospital discharge process and retrospective analysis of hospital admissions by GP and through disease registers.