*Patient Involvement in the Management of Long Term Chronic Conditions Flashcards
Define chronic condition.
Conditions that can be controlled but not cured.
Identify some ways in which chronic conditions affect quality of life.
1) Education (missing class)
2) Sleep (keep waking up)
3) Fitness (can’t even walk without pain)
4) Independence (need someone even to go to the bathroom)
5) Moods (easily frustrated)
6) Appetite/eating
7) Family (parent had to give up work to care)
8) Social life (can’t see friends anymore)
Identify examples of chronic conditions.
Asthma Diabetes IBD Cancer Arthritis
What is the difference between acute and chronic conditions wrt to the level of involvement of the patient ?
In acute conditions, patients are often passive recipients of care.
In chronic conditions, patients must be co-partner in the process (central role in decisions about their illness).
What are some ways in which we can better the management of patients with LTCs ?
- Effective partnership between people with LTC and proactive multi-professional care team
- Offer personalised care plan for those who are most vulnerable and at risk
- Move from secondary to primary community care
- Develop effective and systematic approaches to managing people with LTC
- Government and local initiatives (e.g. LTC action plan with an emphasis on self-efficacy and self-management)
- Integrated services (i.e. both health and social care)
- Use of evidence-based medicine and clinical guidelines supported by standards, education, practice, and managed clinical network (MCNs)
- Use of data collection, quality framework, government performance targets (e.g Health, Efficiency, Access, and Treatment, i.e. HEAT targets)
Identify the key finding of the report published by the Health and Social Care Alliance in Scotland.
People with LTC want holistic support that includes emotional and psychological support as part of an integrated service and not just as an “add on”
Define managed clinical networks.
“Self-supporting groups of professionals working together to ensure cross-speciality sharing of patients and expertise.”
Give another name for HEAT targets.
NHS Fife Local Delivery Plan
Give examples of HEAT targets/Local Delivery Plan, explaining the rationale behind these.
For breast, colorectal and lung cancer:
-31 days from decision to treat (should start treatment of first stage cancer)
-62 days from urgent referral with suspicion of cancer
Because early diagnosis and treatment improves outcomes.
-People newly diagnosed with dementia will have a minimum of 1 years post-diagnostic support
Enable people to understand and adjust to a diagnosis, connect better and plan for future care
Describe Wagner’s Model for Long Term Conditions.
- The model claims that quality of support of people from chronic conditions is improved if action if taken to create conditiond that support a productive partnership, one that empowers people with TLCs and one that is very proactive.
- This model has six quality dimensions:
- Patient centered: Providing care that is responsive to individual patient preferences, needs and values an assuring that patient values guide all clinical decisions
- Safe: Avoiding all harm to patients from care that is intended to help them
- Effective: Providing services based on scientific knowledge
- Efficient: Avoiding waste, including waste of equipment, supplies, ideas and energy
- Equitable: Providing care that does not vary in quality because of personal characteristics such a gender, ethnicity, georgraphic location, or socio-economic status
- Timely: Reducing waits and sometimes harmful delays for both those who receive care and those who give care.
Describe the stepped care model for people with LTC (from an organisation perspective).
• Pyramid:
- At the bottom, population wide prevention, health improvement, and health promotion
- One step up, level 0: inequalities targeted high risk primary prevention
- One step up, level 1: self-management
- One step up, level 2: disease/care management (for poorly controlled single condition)
- Final step, level 3: Intensive case/care management (for complex co-morbidity)
• People can move up or down pyramid depending on how symptoms fluctuate
and how disease changes
- Professional care involved with levels 0 to 3.
- Challenge is to shift towards care that reduces flare up (i.e. not level 3)
Refer to diagram on slide 17 of lecture on “Patient Involvement in the Management of Long Term Chronic Conditions”.
Describe the chronic pain Scotland service model.
Level 1= Advice and info about pain and what to do about it. Anyone can access these services from home/community setting.
Level 2= When help from a GP or therapist is needed
Level 3= For those needing more specialist help from a chronic pain management service
Level 4= Highly specialised help (minority of people)
People at higher levels also make use of the other levels (i.e. level 4 users can also use levels 3, 2, and 1 services etc.)
Identify the main principles of self-management.
- Be accountable to me and value my experience
- I am the leading partner in the management of my health
- I am a whole person and this is for my whole life
- Self-management does not mean managing my LTC alone
- Clear information helps me make decisions that are right for me
In the stepped care model for people with LTC, level 1 is self-management. Explain what it involves, and identify the proportion of LTCs which involve this.
Collaboratively helping individuals and their carers to develop the knowledge, skills (empathy, listening), and confidence to care for themselves and their condition effectively.
70-80%
In the stepped care model for people with LTC, level 2 is disease specific care management. Explain what it involves, and identify the proportion of LTCs which involve this.
Providing people who have complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams and disease-specific protocols and pathways such as the National Service Frameworks and Quality and Outcomes Framework.
15-20%
