Long term conditions and multimorbidity Flashcards
Define long term condition.
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
Graph relationship between obesity and type 2 diabetes mellitus.
Refer to slide 8
Graph relationship between obesity and mean age of onset of DM II.
Refer to slide 9
How is obesity related to diabetes ?
- Insulin resistance is closely linked to abdominal obesity
- As body weight increases, insulin resistance increases
- Reducing abdominal obesity improves insulin sensitivity
How much does weight loss increase life expectancy among obese diabetic patients ? What are other benefits of weight loss ?
5% weight loss = 4.5 kg = 22% of excess wt = 40% of excess abdominal fat
Reduces blood pressure, improves lipid profile, glycaemic control
What number of people are diagnosed with type 2 diabetes in Scotland ? How many people in Scotland are at high risk of developing type 2 diabetes ?
17, 000 diagnosed with type 2 diabetes
500, 000 people at high risk of developing type 2 diabetes
Identify the top 3 long terms conditions in Scotland in terms of number, cost, and beddays.
NUMBER OF INDIVIDUALS
1) Arthritis
2) Asthma
3) Cancer
TOTAL COST
1) Cancer
2) Arthritis
3) Diabetes
TOTAL BEDDAYS
1) Arthritis
2) CHD
3) Cancer
What is SPARRA: Scottish Patients at Risk of Readmission and Admission ?
Risk prediction tool
• Identify those patients most at risk of emergency admission in the coming year
• Feed back probabilities and details of patients to front-line teams
• As basis for:
Further assessment to identify those patients who will benefit most from preventive interventions e.g. intensive case management
Describe the case management approach for high health gain individuals in Fife ?
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 admissions, require out of hours services less frequently and have fewer GP consultations
Identify some key elements of early detection of diabetes. Who is this aimed at ?
Those at risk
- Self-assessment risk
- Professional risk stratificatin
- Accessible info
- Weight management programmes
Identify some key elements of early intervention of diabetes for high risk people.
- Professional risk stratification
- Early diagnosis
- Targeted support
- Specialist intervention
Identify some key elements of early intervention of diabetes for patients with type 2 Diabetes.
- Early diagnosis
- Structured education
- Specialist education
- Person-centered care plans
Graph number of chronic disorders by age group.
Refer to slide 18
Graph percentage of patients with two or more conditions, depending on age, for different deciles of deprivation.
Refer to slide 19
Identify new approaches towards life conditions.
- NICE Guidance
- SPARRA
- Good Conversations
- ADL Lifecurve Approach
- New GP contract?
- High Health Gain
- Patients initiative
Describe the Good Conversations approach to long term conditions.
Approach which aims to engage with the person and significant others to find out what matters to them, what they hope for and what they want to be different in their lives. An outcomes approach involves thinking about what role the person themselves might play in achieving their outcomes, which can be a significant shift from more traditional services where the solutions are viewed as located on the service side.
Describe the ADL lifecurve approach.
Tool used to map age related functional decline. It provides a framework for understanding the most appropriate stage to intervene and which interventions are most effective.
Draw the ADL lifecurve.
Refer to slide 25
Describe the New GP Contract.
“Joint agreement between the Scottish Government and the BMA, which aims to improve access for patients, address health inequalities and improve population health”
Describe the link between expenditure and proportion of service users.
- 3% of population are responsible for half of expenditures (these are high health gain individuals, tend to have more long term conditions)
- 7% of population are responsible for 5% of expenditures
How are high health gain individuals identified ?
Clients identified using a risk stratification tool - High Health Gain developed by ISD
Primary and secondary care data triangulated
Based on past medical history, number of LTC,
number of emergency admissions
Frailty scores utilising a focused Frailty tool.
Distinguish between the new, and old model of case management for high health gain individuals.
OLD
- Single issue focussed
- Crisis management and late presentation
- Heavily dependent on bed based care
- Disjointed
- Episodic – cases closed, discharged
NEW
- Integrated care focussed on LTC’s and frailty
- Timely identification and proactive care
- Care delivered as close to home as possible within communities
- Services joined up with single point of access
Describe prevention of LTCs.
- Prevention strategies focus on some key issues that contribute to high burden LTCs – physical activity, mental wellbeing, healthy diet, and reducing substance use
- Have to be informed by our understanding of the impact of deprivation, adverse childhood experiences, and trauma
What is the public health priority number 6 ?
About healthy weight, diet, physical activity
