3. Local Opportunities (summary) Reduction in admissions to secondary care – proactive case management Whole systems planning and commissioning Recognising & valuing prexisting services Workforce development – education & training New ways of working Opportunity to develop new roles within integrated teams – complex case management Expert patient programme

4. HVOP PNDN NP Chronic Case Management Care ManagementCase Management for Population High Risk PatientsHigh Complex Needs Level 1 Level 2 Level 3 Health Promotion

5. Role of the Primary Care Practitioner/ Nurse Practitioner for Older People (Summary) Focus on a target population within a geographic locality Skilled in undertaking a comprehensive history leading to the instigation of therapeutic treatments in order to improve health outcomes Through joint working with primary care ascertain diagnosis and treatment plans with timely follow-ups as part of caseload management

6. Using advanced skills and expert knowledge identify subtle changes in the persons condition Discuss early signs of ill health Working in partnership with GPs and the Community Nursing Team in developing active therapeutic care plans Manage a case load based on chronic disease management Lead the development, implementation and evaluation of protocols, policies and integrated care pathways

7. Chronic disease represents a significant and exciting challenge for the NHS. Good chronic disease management offers real opportunities for improvements in patient care and service quality and a reduction in costs. Department of Health 2004