Long term condition management
We are supporting primary care teams across our partnership and are providing a long-term condition management support package based on new pathway development, virtual consultations, digital solutions and optimal use of the wider primary care team.
COVID-19 has placed unprecedented pressure on our health system. Immediate focus has understandably been on supporting patients with or at risk of the virus. However, there is a large cohort of people living with long-term conditions that need ongoing, proactive management to prevent a wave of exacerbations increasing health care demand in the months ahead.
As a result of the dramatic changes in the way we deliver primary care to our patients we need to create new ways of working that help patients and clinicians adapt to the new world.
Long-term condition support package
Our team, led by GPs and pharmacists, have developed a long-term condition framework and comprehensive support package for stratifying care according to level of risk with new models of care based on four core principles:
- Virtual by default
- Mobilising the wider workforce (including pharmacists, HCAs, nursing associates, social prescribers and others
- Step change in support for self-management
- Digital innovation, including tools for self-management and technology for remote monitoring
The conditions we are focussing on are:
- Type 2 diabetes
- Chronic Obstructive Pulmonary Disorder (COPD)
View the full support package
As part of our package of support we can also provide clinical and project management support for local pathway adaptation, plus training/education for HCAs, pharmacists and others, including virtual workshops, webinars and communities of practice.
Local health systems who commission our support can expect to receive implementation and clinical support to:
Identify patients with long-term conditions
- Pre-defined searches with Sno-Med/Read codes with guidance as to how to implement
- Virtual training to undertake and access targeted searches
Stratify their risk
- Proposed stratification thresholds
- Clinically-led specialist training sessions on specific long-term Conditions to build understanding of these conditions
- Virtual clinical advice and support, where required
- Identified staff roles to undertake interventions according to risk group – low/ medium/ high
- Protocols for staff to follow informed by patient/ public feedback and behavioral insights specialist – which can be tailored to reflect local contexts
- Virtual training sessions for different staff types with content adapted to the needs of the individual staff, e.g. HCA, clinical pharmacist and including practical training to health coaching to communities of practice
- FAQs for each staff type involved
Implement digital self care resources
- Implementation training and support, where needed, for digital solutions to enable patients to self-manage in the home setting.
To find out more about this offer and how to implement it in your locality please email firstname.lastname@example.org