Long Term Conditions and Multi-Morbidity

Question 1

Define long term conditions

Answer 1

“Long term conditions are health conditions that last a year or longer, impact on a person’s life, and may require ongoing care and support”

Question 2

What is the burden to the NHS of LTCs?

Answer 2

78% of all NHS resources

Question 3

What do LTCs have a major link with?

Answer 3

Deprivation

Question 4

Describe the epidemiological relationship between diabetes, BMI and obesity

Answer 4

• The number of people with diabetes in Scotland is increasing
• String links with coronary issues and obesity
• As BMI ibcreases the risk of diabetes increases exponentially
• High BMI is likely to result in an earlier onset of T2DM
• Females = higher risk

Question 5

Describe the impact of visceral obesity on diabetes

Answer 5

• Insulin resistance is closely linked to abdominal obesity
• As body weight increases, insulin resistance increases
• Reducing abdominal obesity improves insulin sensitivity

Question 6

What is the impact of weight loss for patients with diabetes?

Answer 6

• Increased life expectancy
• decreases blood pressure
• improves lipid profile
• improves glycaemic control

Question 7

What are the 4 core components of the diabetes framework?

Answer 7

• Prevention - whole population
• early detection - those at risk
• early identification - those at high risk
• early identification - those with T2DM

Question 8

What are the main methods used in tackling long term conditions and multi-morbidity?

Answer 8

• NICE Guidance
• SPARRA
• Good Conversations
• ADL Life curve Approach
• New GP contract?
• High Health Gain Patients initiative

Question 9

What is SPARRA?

Answer 9

Scottish Patients at Risk of Readmission and Admission

• Identify those patients most at risk of emergency admission in the coming year
• Feedback probabilities and details of patients to front-line teams

Question 10

What are good coversations?

Answer 10

Personal outcomes and asset-based approach

focus on what matters most and what outcomes an individual wants to achieve

Question 11

What is meant by the new GP contract?

Answer 11

So GPs can provide for complex needs rather than discrete episodes of care (primary care improvement plan)

Question 12

What is meant by high health gain patients initiative?

Answer 12

targeted proactive case management

Question 13

What is the case management plan approach in fife for high health gain individuals?

Answer 13

• Integrated approach to care co-ordination for individuals identified as high health gain
• Provide targeted proactive case management
• Engaging with people in their communities to minimise crises
• People will experience greater independence and participation in their valued activities from improved health and wellbeing
• People will have fewer unplanned hospital admission, require out of hours services less frequently and have fewer GP consultations

Question 14

How are high health gain individuals identified?

Answer 14

• Clients identified using risk stratification tool – High Health Gain developed by ISD
• Primary and Secondary Care data triangulated
• Based on PMH, number of LTC, number of emergency admissions
• Frailty scores utilising a focused frailty tool

Question 15

What is the new model of management of high health gain individuals?

Answer 15

• Integrated care focused on LTC’s and frailty
• Timely identification and proactive care
• Care delivered as closer to home as possible within communities
• Services joined up with single point of access

Question 16

What are the outcomes underpinning the diabetes preventuon and early intervention network?

Answer 16

• Outcome 1: Children have the best start in life – they eat well and have a healthy weight
• Outcome 2: The food environment supports healthier choices
• Outcome 3: People have access to effective weight management services
• Outcome 4: Leaders across all sectors promote healthy diet and weight
• Outcome 5: Diet-related health inequalities are reduced