The NHS and Social Care long term conditions model draws on local and international expertise to improve the health and quality of life for those with long term conditions.

The model:

• Provides personalised and systematic support, based on what works best for people in NHS and social care systems
• Provides a structured and consistent approach to help local health and social care partners deliver integrated care
• Helps ensure effective joint working between all those involved in delivering care, including secondary care, ambulance trusts, social care and voluntary and community organisations. Patients need to experience a seamless journey through the health and social care systems.

Levels of need and care:

• Level 1: Supported self care Helps individuals and their carers develop the knowledge, skills and confidence to care for themselves and their condition effectively. Read more on the Department of Health website
• Level 2: Disease-specific care management Provides people who have a complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams and disease-specific protocols and pathways. These include the national service frameworks (NSF) and quality and outcomes framework (QOF). Read more on the Department of Health website
• Level 3: Case management Requires the identification of high intensity users of unplanned secondary care. Care for these patients is to be managed using a community matron or other professional to join up health and social care. Read more on the Department of Health website