Long Term Conditions

Often a crisis, like a fall for an older person or for someone with a long term condition, is a predictable and preventable event. However, for the majority of patients, being admitted to hospital is all too common.

Our aim is to create an enhanced service which offers high quality care for people with long term conditions (LTCs), based on a joined-up and integrated approach.

By investing in proactive integrated care, we expect to enhance the whole system of care for patients with LTCs in Leicestershire, to improve independence and choice on a 24/7 basis.

This will mean that together, we can detect more patients with a LTC so treatment can be started earlier and therefore hospital admissions can be avoided for the majority.

The main aims of LTCs:

  • Detect more patients with a LTC so treatment and care planning can be started earlier.
  • Provide more support for patients with a LTC to prevent the condition from getting any worse.
  • Treat more patients in the community and reducing the amount of time they spend in hospital.

Integrated Proactive Care

Across Leicestershire, we have developed effective models of care to support and maintain the maximum level of independence and self-care possible.

This involves ‘risk stratification’ and care planning, with primary and community based support planned around the patient, carer and family. Risk stratification identifies those individuals most at risk of being admitted to hospital, or those who are likely to reach a health crisis.

Integrated Proactive Care enables a positive and combined approach, which allows the individual and the health and care teams to work together to achieve the level of support needed.

The model successfully allows patients in the community to have care managed by locality based teams, working with General Practice as an integrated service, using the established community and social care resources within each locality.

Integrated Care – East Leicestershire and Rutland CCG

Our Integrated Care programme, which was implemented in 2012, is a partnership between social care, community nursing and GPs throughout East Leicestershire and Rutland. It provides a chance for patients to address, not only their specific long term health conditions, but also how these affect all aspects of their life and the people around them.

Patients who have complex needs, involving multiple long term health conditions, and whose care may deteriorate without proactive support and review, are identified using a risk assessment tool along with GP knowledge of their condition(s) and case history. They are then contacted by their local Integrated Care Co-ordinator to discuss their current situation and needs, using an assessment tool co-designed by health and social care staff.

This information is then used in multi-disciplinary team meetings in each surgery involving GPs, community nursing and other partners, so that care is carefully planned and coordinated between professionals, the patient and their carer/ family members.

Evidence obtained from similar approaches in other parts of England, including the King’s Fund Integrated Care model, demonstrates the impact of this approach on supporting people and maintaining their quality of life for as long as possible.

For more information about the Integrated Care Service please contact:

Aiden Neaves – Team Senior Integrated Care

0116 305 4832 or email Aiden.Neaves@leics.gov.uk

Proactive Care – West Leicestershire CCG

West Leicestershire CCG’s model of care for managing complex and multiple long term conditions is based upon national and international evidence of best practice, and is called “Proactive Care”. The focus is on frail older people and patients with long term conditions, which include cancer and mental illness. The risk stratification tool is used to identify individuals most at risk of being admitted to hospital or those who are likely to experience a health crisis.

The ‘proactive’ approach is followed where the patient and the care team work together to agree on the support they need to manage their condition and identify the help they need. The engagement with the individual is ongoing and ensures the health risk is kept at bay and supports the individual to self-manage their condition.

The model has been successfully developed through the creation of “Virtual Wards” – locality based teams working with General Practice as an integrated service with established community and social care services.

There are ten virtual wards in West Leicestershire CCG central to the capability of supporting adults to remain in their own homes, maximise their independence and improve health outcomes and quality of life.

Each ward is based on a population of approximately 36,000 registered patients and made up of a group of general practices mostly geographically based. The virtual ward is clinically led by the clinical co-ordinator and supported by registered nurses, allied health professionals and health care support workers who are appropriately trained, experienced and with competencies and skills that are maintained and kept up to date commensurate with their roles.

The virtual ward is supported by a wider multidisciplinary team made up of a range of specialists including community psychiatric nurses, adult social care and Macmillan nurses among others who will support those working through the concept of a virtual ward. This service will link as appropriate to step up interventions such as Intensive Community Support


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