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Support for long-term condition management

To help keep people healthy and well in their homes both during and post COVID-19, we have developed a primary care support package based on new pathway development, virtual consultations, digital solutions and optimal use of the wider primary care team to support management of long-term conditions.

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 in the months ahead. Our package of support is designed to enable primary care teams to continue to provide this management.

The conditions we are focussing on are:

  • Asthma
  • Chronic Obstructive Pulmonary Disorder (COPD)
  • Type 2 Diabetes
  • Cardiovascular disease (including hypertension, heart failure, AF and high cholesterol)

Download our pathway resource for Asthma, COPD and Type 2 Diabetes here.

On 5 May 2020 we hosted a webinar, sharing the package of support on offer for primary care teams. Watch the full webinar below. N.B content correct on 5 May, this support package continues to develop.

This is one part of the resource we are offering which is also accompanied by:

  • Comprehensive search and risk stratification tools developed by Dr John Robson and the Clinical Effectiveness Group (CEG) based at QMUL
  • Detailed protocols for Health Care Assistants (HCAs) consulting with patients stratified to the low risk groups
  • A list of targeted digital resources to support self-management

We are now beginning work on resources for managing patients with heart failure, hypertension, AF, cholesterol.

As part of our package of support we will 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.

Contact us

If you would like to find out more about this offer and how to implement it in your locality please email