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Managing Long Term Conditions

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					Managing Long Term Conditions in
 Durham Dales - ONE YEAR ON
Moving From Patient,to Person Centred
         Case Management

  “People need to be offered the opportunity
   to make informed decisions about their
            health & social care”

  Supporting People with Long Term Conditions- An NHS & Social
  Care Model to Support Local Innovation & Integration DoH (2005)
People with Long-term conditions are
        every one’s business
So who makes up the Durham Dales Long
       Term Conditions Team ?

  • Community Matrons
  • Social Workers
  • Patient Involvement Facilitator
 Long Term Conditions Team Mission
            Statement
To influence, deliver and shape a high quality
service for those people whose lives are affected
by multiple long-term conditions, and whose
health and social care needs are highly complex.
This will be carried out using an integrated case
management approach which is person centred,
proactive and utilises the resource of the locality.
 Aims of the Long Term Conditions Team

1. Adopting the principles of the Unique Care
   model actively manage and integrate care for
   people with very highly complex needs.
2. Ensure public involvement is at the forefront of
   the LTCT service
3. Acting as a Human search engine signpost
   people towards a self management partnership
   between the public and the Health and Social
   care professional
 Aims of the Long Term Conditions Team
1. Adopt a strategic approach and action plan
2. Develop a tracker for effective self management
3. Outcomes should reflect achievement of local need
   within the guidelines of the National Service Framework
4. Develop localised integrated care pathways across social
   care and health
5. Develop a range of awareness and education programmes
   -Expert Patients Programme (generic)
   -Expert Patients Carer Programme “Looking After Me”
   -Disease specific education programmes
    Aims of the Long Term Conditions Team
1.    Develop working partnerships with :
      - Social Care
•     - District Nurses/case managers
      - GP Practices
      - Acute Hospitals in County Durham
      - Community Hospitals Barnard Castle / Stanhope
      - Integrated Health and Social Care locality teams
      - Volunteer sector
      - Expert Patients Programme Regional team
      - Local support groups and other agencies
 Identification of Appropriate People who
          meet the LTCT Criteria

• Hard data:
      •   Acute Hospital admission data from shared services disc
      •   Kings Fund PARR2 Predictive Tool
      •   Egton Medical Information System ( EMIS )
      •   Social Services Information Data Base ( SSID )
      •   Expert Patients Programme Data Base ( EPP )
      •   LTC Excel Spread Sheet/shared services
      •   Community Hospital (Stanhope / Barnard Castle )
 Identification of appropriate people who
          meet the LTCT criteria

• Soft Data: (referrals from other colleagues)
       • Local knowledge from Health and Social Care
         Professionals / Non Statutory Agencies /Carer
         Groups
       • Personal knowledge from patients / carers / family
         members
       • Expert Patient Programme participants feedback and
         testimonies
       • Patient / user Questionnaires
     Operational Outcomes To Date
                2005 / 2006
( Two GP Practices working with the NPCC )
The LTCT working in partnership with the National Primary
 Contracting Collaborative in two Practices out of thirteen


 22% Reduction in bed days
 17% Reduction in admissions
Bed Day Operational Outcomes To Date
         (all GP Practices)
13 GP Practices in Durham Dales    2004 / 2005
Total bed days 12 months           27652

13 GP Practices in Durham Dales    2005 / 2006
Total bed days 8 months actual     16107

13 GP Practices in Durham Dales 2005 / 2006
Total bed days projected 12 months 24160

Total bed days projected potential reduction 12 months
                   12.7%
       Average Costs per Admission

• Based on the LTC codes as identified by The
  Kings Fund.
• Coupled with admissions 2005 to January 2006
• Durham Dales average cost per admission = £951
• Review of savings with only one DD resident
  shows a post LTCT saving of
                  £ 9,510
Avoiding ONE Admission per Week
• If all 13 Durham Dales Practices avoided one
  admission per week, this would release money for
  re-Investment to the tune of


……………£ 642,876…………….
Your Operational Outcomes To Date?




       £???????
          tba
  Operational Outcomes To Date 2005 - 2006
       Baseline Caseload    Case Management Outcomes
Qtr 1 - : 20               Qtr 1 - : 20

Qtr 2 - : 40               Qtr 2 - : 60

Qtr 3 - : 60               Qtr 3 - : 70

Qtr 4 - : 80               Qtr 4 - : 88
      Moving from Patient to Person

Managing Long Term Conditions in Durham Dales
Moving From Patient,to Person Centred Case Management
So who makes up the Durham Dales Long Term Conditions
Team ?
Long Term Conditions Team Mission Statement
Aims of the Long Term Conditions Team
Identification of Appropriate People who meet the LTCT
Criteria
Operational Outcomes To Date
People with Long-term conditions are
        every one’s business

				
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Description: Managing Long Term Conditions