1. NHS Stoke on Trent 270,000 registered patients, 54 GP practices 2 new GP practices and GP led Health Centre planned for 2009 Some of the most deprived wards in England, 5 PBC clusters closely aligned with the Local Authority neighbourhood areas WM AHSN clinical priority: Long Term Conditions Professor Ruth Chambers OBE, GP & Clinical telehealth lead, Stoke-on-Trent CCG Honorary professor Keele & Staffordshire Universities

2. AHSN Long Term Conditions Priority Integrated Care Adoption & Diffusion Education & Training Wealth Creation Digital Delivery Clinical trials Mental health Drug safety LTCs

3. It’s about the basics improving delivery of best practice care for long term conditions via patient empowerment, integration & innovation 3 Best clinical practice & shared management Tech Improved QUALITY of clinical care

4. Most people with any long term condition have multiple conditions (eg Scotland)

5. – The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions – More people have 2 or more conditions than only have 1 Multimorbidity is common in UK

6. People with multimorbidity are much more likely to have emergency and potentially preventable admissions

7. International evidence shows that people with multimorbidity experience more problems with the coordination of their care

8. Personal responsibility & self care Right treatment for LTC, right delivery, right time, right team, right intensity

9. Supporting people at home Enhanced support at home Manage Crisis Effectively Specialist acute input Digital delivery can support the whole patient pathway Enhanced support at home Supporting People at Home Manage step down from acute effectively Crisis AcuteTrf of care Home Support* Support Long term hypertension Smoking Cessation Long term vital signs monitoring Care Homes Pain Mment Medicines Management “Worried Well” INR Weight loss motivational messages Health self assessment Sexual health Unstable Hypertension Newly diagnosed hypertension Medication Reminders for: - Hypertension / Ashma inhaler / pain management Paediatric ashma COPD Diabetes (type1& 2) Heart Failure Palliative care carer support/wellbeing Falls prevention Virtual Wards Intermediate care Step down facilities Unstable vital signs monitoring Medication management As * Pregnancy induced hypertension Gestational diabetes COPD CHD Diabetes physiotherapy Monitoring of pre op patients to reduce cancelled operations Out patient acute specialist follow up DNA management Support early discharge EMAS unstable vital signs monitoring Oncology Neurology Speech therapy Alcohol support Learning disabilities Mental health behaviour Mental Health appt & medication reminders/ supportive messages Daily living/ medication reminders for people with Aspergers/autism Long term hypertension Smoking Cessation Long term vital signs monitoring Care Homes Pain Mment Medicines Management “Worried Well” INR Weight loss motivational messages Health self assessment Sexual health

10. Palliative Care Cardiac Rehab R apid Access CP Clinic None Pharmacological Interventions Inpatient Care Out patient Cardiol ogy A/E Education Patient Self Care Weight Management Fluid Restriction Symptom Monitoring Lifestyle Changes Primary Care Core GP Service Tier 3 Service MDT HF Nurse Education/Training/Support Individual Management Plans Worsening Symptoms Despite Treatment Home SC Diuretics Consultant Assessment Accredited GP/ PN HF Nurse Support Individual Management Plans GP Community Matron Practice Nurse District Nurse Urine Analysis Full Blood ECG BNP CXR Drug Therapy History Examination Manage Co-morbidities ECHO Manage Co-morbidities Organise Follow-up

11. WMAHSN LTC stakeholder consultation –so far LTCs Asthma COPD Hypertension Heart failure OA AF Diabetes & obesity Virtual patient information leaflets /app Integration Education Wealth creation Adoption & diffusion Digital delivery Clinical champions; patient champions Beacon sites; rollout GP/social care integration Computerised decision supportWeb resource Flo telehealth- exemplars Databases: successful LTC innovations, patient stories, shared management plans Patient upskilling eg avatar, apps Themes Program Interventions Empowering patients Shared management Upskilling patients

12. Helping patients to help themselves 12 Readings & answers Opt-in/out, prompts, questions, feedback, advice, education all my teams clinician smartphone web patients mobile phone Alerts if needed Closed loop £ free to txt

13. Working with industry Designed for collaboration 13 Enabling an industry & academia eco- structure, building on the core

14. Working with CCGs: eg risk profiling – underpinning evaluated innovations Level 3: High Complexity Case Management Level 2: High risk Disease/Care Management Level 1: 70-80% of LTC population Self care support/management Low cost, large-scale: ‘simple telehealth’

15. Focus on patient perspectives of clinical conditions? Enriching self care as agreed shared management Helping people to help themselves – as agreed with their clinicians – throughout all tiers of care

18. Looking forward ?