managing long-term conditions at home

Outline service profile of comprehensive preventive care

Personal Health Advisor

Named advisor building relationship with patient/person and carer, understanding what matters and co-creating package of services

Concierge/ Assisted Self-Service

Operational support for set-up/booking of services and provision of supporting tech. Help with running a personal daily schedule

Carer Empowerment

Help carers provide effective support with contacts, advice, education and digital access.

Education

Build understanding and confidence through bite-sized LTC education modules and group sessions

Vital Signs Monitoring

Enable, remind, encourage, incentivise patient to take vital signs regularly.

Mutual Member Support

Helping patients build network of members with similar issues and receive and give mutual support

Physical Activity & Diet

Remind, encourage, incentivise patient to take appropriate exercise and eat healthily.

Medications Adherence

Remind, encourage, incentivise patient to take medications as and when prescribed.

Local VCSE Services

Enable access to and participation in local services offering advice on housing, debt, employment, benefits; active pursuits; social activities and spaces

Passive Monitoring

Monitor activity related to activities of everyday living. Identify abnormalities which may be predictors of ill-health or the need for social intervention.

Citizen / Patient / Carer

Managing one or more LTCs at home.

The NHS England has developed this risk stratification for patients with chronic illness

In these terms, our focus is on Rising-Risk Patients, those who:

  • are living at home having been diagnosed with one or more long-term conditions
  • are left by default to self-manage, possibly with support from family or carers
  • once activated, would manage better if supported to take medications as prescribed and if they monitored relevant vital signs
  • could be supported to optimise quality of life and avoid acute exacerbations for as long as possible

In time, these patients will present in large numbers in primary care, in ED and will occupy acute bed capacity.

They will also require substantial social care support and, in time, residential care.

With effective support to manage their conditions more successfully, the demand on health and social care capacity can be mitigated and delayed.

      There are wide-ranging benefits from better preventive care

      Service Objectives

      Improve patient / citizen & carer wellbeing with reduced inequalities

      Measured Benefits

      • Prevented/slower progression of individual LTCs & acquisition of new
      • Improved and sustained patient activation
      • Improved Patient’s self-assessment of wellbeing
      • Increased earnings (if patient of working age)

      Beneficiaries

      Patients and carers

      Reduce demand on NHS service capacity and £

      Measured Benefits

      • Better value from prescribed medications
      • Reduction in unplanned GP attendance / appointments
      • Reduction in Community Nurse / Therapist visits
      • Reduction in avoidable ED attendances
      • Reduction in avoidable acute hospital admission & bed days

      Beneficiaries

      Trusts, Practices & Staff

      Reduce / delay demand on Local Authority service capacity

      Measured Benefits

      • Delay in need for at-home social care package &/or residential care

      Beneficiaries

      Local Authorities

      Improve economic participation

      Measured Benefits

      • Increased economic contribution (tax, community, caring) from patient

      • Increased economic contribution (tax, community, caring) from carer

      • Reduction/containment in national benefits payments

      • Higher utilisation of local assets (VSCEs, local estates etc.)

      Beneficiaries

      Whitehall / HMRC

      Summary rationale for this focus on patients managing long-term conditions at home

      1. More than 25% of the adult population is managing one or more long-term conditions at home. Without better support, many will soon require interventions from primary and acute healthcare and social care services.

      2. With remote monitoring and social support, self-management is more effective with positive outcomes: for citizen well-being and reduced pressure on health and care services.

      3. Support can be targeted to address unacceptable health inequalities: economic, geographic, ethnic and racial. Often a combination of several factors.

      4. Some of the capabilities required to deliver such a service successfully already exist in local health systems. Refocus and re-energizing these capabilities, with some incremental investment, can create momentum to a comprehensive, robust and scalable solution.

      5. This is a tangible and credible way to deliver on the prevention agenda while at the same time addressing inequalities: staff will get behind it.