Managing Chronic Disease

CLAHRC East Midlands is hosted by

Nottinghamshire Healthcare

Sally Singh, Theme Lead, MCD Theme

Background

15.4 million people in England have a long term condition

People with long term conditions use a significant proportion of health care services (50% of all GP appointments and 70% of days spent in hospital beds), and their care absorbs 70% of hospital and primary care budgets in England.

Cardiovascular diseases account for most deaths (17.3 million worldwide), followed by followed by cancers (7.6 million), respiratory diseases (4.2 million), and diabetes (1.3 million).

They share four risk factors: tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets.

Outcome frameworks

• Health-related quality of life for people with long-term

conditions

• Improvement areas

• Ensuring people feel supported to manage their LTC

• Improving functional ability in people with LTC

• Reducing time spent in hospital by people with LTC

• Enhancing quality of life for carers

Overarching indicators

Strong track record of research and innovation

Excellent research infra-structure across the EM

(Biomedical Research Units)

National Centre for Sports and Exercise Medicine

Why us?

• Long term conditions-

• the use of IT systems to support decision making and delivery of care

(diabetes and chronic kidney disease)

• interventions designed to support and educate patients

(COPD and cardiac disease).

These are components of an integrated care pathway that personalise

and stratify care appropriately; an important feature of the overall

strategy to manage chronic disease

Our proposed areas of focus

To develop an effective primary care intervention to reduce

mortality and morbidity in patients with type 2 diabetes and

(Kamlesh Khunti Leicester &Nadeem Qureshi, Nottingham).• An intervention at GP level using GP computer prompts in

conjunction with enhancing the skills of key practice staff, with the aim of supporting individuals with microalbuminuria and diabetes, who are at high risk of CVD and CKD.

• To test for feasibility and generalisability of this approach in the East Midlands.

Our projects (1)

• The IMPAKT CKD tool (Nigel Brunskill)

Our projects (2)

IMproving Patient care and Awareness of Kidney disease progression Together

Aim - to use a primary care informatics solution to identify patients with chronic kidney disease (CKD) and other long term conditions in primary care who are at risk of AKI, needing unscheduled care or acute admission. - to deliver a self-management intervention to prevent admission.

• Self management - for COPD (Sally Singh & Katy Mitchell)

• Previously tested a supported self management approach

• Aim - to test wider roll out and local delivery based in primary

care

Our projects (3)

• Maintenance post cardiac rehabilitation (post MI patients)

To determine whether implementation of a structured education and physical activity

programme in primary care, to people who are at high future risk of diabetes following a

myocardial infarction, will reduce cardiovascular risk and dysglycaemia

• Use of technology in cardiac rehabilitation (web based intervention)

To determine whether a Web-Based Cardiac

rehabilitation programme is a realistic

alternative for those declining or dropping

out Of conventional rehabilitation

Our projects (4)

Thank youMLTC theme contact: sally.singh@uhl-tr.nhs.uk

www.clahrc-em.nihr.ac.uk

@CLAHRC_EM

This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East Midlands (NIHR CLAHRC EM). The views expressed in this presentation are those of

the speaker(s) and not necessarily those of the NHS, the NIHR or the Department of Health.