New Horizons - LTC Janette Barrie/Marjorie McGinty Horizons Long... · New Horizons Long Term...

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New Horizons Long Term Conditions

Transcript of New Horizons - LTC Janette Barrie/Marjorie McGinty Horizons Long... · New Horizons Long Term...

Page 2: New Horizons - LTC Janette Barrie/Marjorie McGinty Horizons Long... · New Horizons Long Term Conditions. ... • LTCAT = LTCC Programme Board • Wide stakeholder membership •

Years of this…

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2000 – 2050: The Legacy

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Rising at all ages…People reporting a chronic condition (by age)

0

10

20

30

40

50

60

70

80

1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002

Year (note: data from1998 is w eighted)

% o

f sam

ple

0-4y

5-15y

16-44y

45-64y

65-74y

75+

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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

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• 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

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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

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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

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By 2030 incidence of LTCs in the over 65s will have doubled

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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)

Page 12: New Horizons - LTC Janette Barrie/Marjorie McGinty Horizons Long... · New Horizons Long Term Conditions. ... • LTCAT = LTCC Programme Board • Wide stakeholder membership •

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

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Current systems……Medical model still

existsSystem is not

seamless

Too many “hand offs”

Lack of co-ordination

People lost during transitions

Change is essential

Poor communication

Need continuity

Lack of information

Inequity of care

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Other concerns……• Carers issues• Transition from child services to

adult care and older adult• Non-adherence / concordance• Impact on family

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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

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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

Page 17: New Horizons - LTC Janette Barrie/Marjorie McGinty Horizons Long... · New Horizons Long Term Conditions. ... • LTCAT = LTCC Programme Board • Wide stakeholder membership •
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Long Term Conditions Collaborative

• Collaborative methodology• LTCAT = LTCC Programme Board• Wide stakeholder membership• National and Regional Team• National Improvement Measures• 4 Workstreams

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COPD Self Management

First Hand Experience

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Condition Management

• MCNs Clinical pathways• CSIGs Clinical & Service Models• Optimising roles• Clinical support & training• Carer support & training• Neurology

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Complex Care

• Integrated Care Management• Care Homes Support• Palliative Care (malignant & non

malignant)• Anticipatory Care Plans• Community Hospitals

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Information & Evaluation

• National improvement measures• Local improvement measures• Logic Model approach