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Long Term Conditions Programme

Personalised Care

Planning

For a better quality of life

For People with Long Term Conditions

KATHRYN PADGETT

(BA, RGN, RM, RHV)

ASSISTANT DIRECTOR OF NURSING

BARNSLEY CARE SERVICES DIRECT PCT

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Aim of Presentation

Policy Context

What is Personalised Care Planning

What is a Long Term Condition Cost to NHS

Cost to individual (How does it feel)

Barnsleys Vision

Barnsleys Programme

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Health is a state of complete Physical, Mental and Social

Well-being and not merely the absence of disease

World Health Organisation

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Policy Context

Long Term Conditions ProgrammePersonalised Care Planning

DH CommitmentsOur Health, Our Care, Our Say White Paper

Commitments:

By 2008 we would expect everyone with both long term health and social care needs to have an integrated care planif they want one.

By 2010 we would expect everyone to have a care plan

NHS Next Stage Review High Quality For All (2009) and Primary and Community Care Strategy re-affirms the offerof care plans for 15m people with a long term condition

The Operating Framework for the NHS in England 2009-10.

Over the next 2 years, to ensure those living with a long term condition receive a high quality service to manage theircondition, everyone with a long term condition should have a personalised care plan

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Long Term Conditions Programme

What is personalised care planning

Personalisation has become key concept for the future of the NHS

Health and Social Care Systems sharing services around the needs ofindividuals not the other way round NHS Plan (2000)

Goal Setting and outcomes

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What are Long Term Conditions?

Health problems that require ongoing management over a period ofyears or decades

They are NOT curable and last longer than 12 months

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Staggering Stats

1 INCIDENCE

Almost one in three of the English population suffer from a LTC

2 Cost to the NHSAdmission 1658Moderate exacerbation managed by GP at home 95Mild exacerbation self managed 15

3 Department of Health Summary of Self Care Impact

17% Decrease in outpatients visits40% Decrease in number of primary care consultation50% reduction in A & E Visits

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Economic Reality Barnsley

NHS Crunch

Population nearly million

Rising Birth Rate

High Level Disadvantage

Benefits paid to those unable to work due to illness ordisability nearly twice the national average

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Self Directed Care

Our vision within Barnsley is to

Have

People maximise their aspirations for control and

independence over their health and well-being supportedby flexible, responsive, preventative, services.

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Long Term Conditions Programme

What does it mean for the person with a LTC?

What is important to me,

what I want to do: I want tolive at home, I want to returnto work, I want to get out

more, I want more suitablehousing

I dont feel myself, I am

lonely, I am anxious, I feelbreathless, I feeldepressed

I want to understand mycondition better, I didnt

listen properly to mydoctor, I was confused

I am confused by all of

the medication I have totake

I want information onhow to access

benefits

I want information onhow to get back intoeducation

I want reliable, trustworthyinformation on my condition

generally

I want access to asupport network

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Long Term Conditions Programme

What does it mean for the person with LTC?

How does it feel for the person:

I am scared ifmy condition

deteriorates Ijust dial 999

I want to planwhat to do- whoto contact first

i want the hospital staff to knowwhat my wishes are if I am

admitted (the process goes with

them to the hospital) I want themto know about my care plan and

they need to know certain thinkgsthat really matter to me

I see lots ofprofessionals andhave to repeat mystory over and over

No-one seems to takethe lead, I dont haveconfidence in them andthat I will get the right

services dont they talkto each other?

Services arescheduled at time

that are not right forme

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Long Term Conditions Programme

Local examples

Care Navigation

Motivational Interviewing and Coaching

Co-creating Care Plans

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HOW BARNSLEY ACHIEVE SELF DIRECTED CARE PROGRAMME

TELECAREFALLS

PREVENTION

PERSONAL BBUDGETS

PERSONALISEDCARE PLANS

TELEHEALTHDOL ATHOME

UNIQUECARE

CARENAVIGATION

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Barnsley Initiatives

Improved access to psychological therapies

Personalised care plans

Telecare Telehealth

Care navigation

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Long Term Conditions Programme

I feel that I have control over my life again

It feels as if everyone is working together to help me

2006/07 12 admissions

2007-08 2 admissions

OUTCOME SHIRLEY

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IN CONCLUSION

More proactive approaches, supporting people to self care freeing up more time to spend onproactive and preventive care

Improved outcomes for patients/individuals and support for their carers and families Supported goals to remain health, independent and sustain or achieve social inclusion deciding for

self

A broader range of choice tailored to what people want, services centred around individuals notother way around listening

Empowered more confidence to self care Knowing more about condition and impact upon life Information for choice and control Better management of medicines More joined up services, less duplication More support for carers Greater ability to work, less time off sick Improved mental health Less reliance on services reductions in emergency admissions People as Assets Equal Partnership

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NHS PLAN 2000

The generic choice model for

people with LTC(Dec 2007 www.dh.gov.uk)

Common Core Principles to

Support Self Carewww.skillsforhealth.org

http://www.dh.gov.uk/http://www.skillsforhealth.org/http://www.skillsforhealth.org/http://www.dh.gov.uk/