5. Key elements for people with long term conditions
- Condition specific information and advice, easily accessed when it is needed
- Personalised, condition specific, care plans that empower people to self manage
- Regular reviews of care plans, including disease management and planned face-to-face medication reviews. Case management and community matron support where needed are part of care planning
- Structured education and training
- Monitoring devices and assistive technology
- Support networks, including peer support, carers and family support groups
- Access to other services in a coordinated and consistent way, including social care, benefits advice and support, housing, transport, leisure, education, voluntary and community services
6. Key expectations for front line staff
- Understand the principles of self care
- Trained to communicate effectively
- Can provide relevant, evidence based information
- Give advice on access to health and social care services, benefits, housing, transport, leisure, education voluntary and community organisations and support networks
- Are aware of relevant resources and technologies
- Help people manage identified risks
- Promote choice and independence based on people’s strengths and abilities
- Pharmacies have a specific role in providing self care support through the new community pharmacy contract. (See document no 14, Pharmacy in England: Building on strengths – delivering the future)
7. Benefits for people with long term conditions
- Increased life expectancy
- Better control over symptoms
- Reduced pain, anxiety and depression
- Greater independence
- Improved quality of life
- Reduction in days off work by 50%
(See document no.’s 7 and 8, Research evidence on the effectiveness of self care support, Self Care Support. The evidence pack: summary of work in progress 2005-07)
8. Benefits for the health service
- Meets NI, PSA targets and strategic ambitions
- Improved quality of consultations
- Improved patient satisfaction
- Reduced visits to GPs by up to 69%
- Reduced hospital admissions by up to 50%
- Reduced hospital length of stay
- Decreased number of days in hospital by up to 80%
- Reduced outpatient visits by up to 77%
- Reduced A&E visits by up to 54%
- Reduced medication expenditure
- Improved medicine utilisation by 30%
(See document no.’s 7 and 8, Research evidence on the effectiveness of self care support, Self Care Support. The evidence pack: summary of work in progress 2005-07)
9. Monitoring progress
- NI124 People with a long term condition supported to be independent and in control of their condition.
- PSA 19 has been reworded to be more outcome focused – People feeling increased satisfaction with the support they are given to be independent and in control of their condition, will be measured as part of the Operating Framework 2009/10 (part of the Department of Health strategic objective Better care for all).
- NHS South West ambition: 75% of general practices will adopt the self-care policy of the locality by 31 July 2009.
Actions to take:
- Decide on how to manage performance and evaluate outcomes, including patient experience and value for money
- Review current local provision of key elements, establish what already exists and identify the gaps and any changes that may be needed
- Identify training needs for frontline staff in order to meet the expectations
- Identify people at risk and local health care inequalities
- Use evidence on costs, benefits and efficiencies gains to make the business case