1. Dominic Blaydon & Sarah Whittle Community Transformation & Long Term Conditions

2. What is a Long Term Condition “ Long-term conditions are those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. The life of a person with an LTC is forever altered. There is no return to ‘normal’.” Department of Health

3. Types of Long Term Condition Hypertension81,144 Diabetes15,486 Chronic Obstructive Pulmonary Disease8,784 Stroke6,595 Multiple Sclerosis3,606 Coronary Heart Failure1,587 Cardio Vascular Disease17,980 Parkinson’s Disease4,637

4. Impact on local health economy 70% of health & social care spend 80% of in-patient bed days 55% of GP appointments 70% of outpatient and A&E attendances

5. What do people with LTCs need? 8 issues that impact on experience of health and care services: Fast access to reliable health advice Effective treatment delivered by trusted professionals Involvement in decisions and respect for preferences Clear, comprehensible information and support for self-care Attention to physical and environmental needs Emotional support, empathy and respect Involvement of, and support for, family and carers Continuity of care and smooth transitions

6. Risk stratification Case management – Single budget and manager Single point of access Patient skills programmes – Self management Psychological support Practitioner skills programmes Effective joint governance arrangements Aligned incentives - through new financial models Data sharing with real time access How to improve services

7. Social prescribing is a framework for linking patients with non-medical needs affecting their health, well- being and ability to self-manage, to sources of support within the community. Social Prescribing – What is it? PRESCRIPTION Exercise / healthy lifestyles Self-management programmes Social and leisure Arts and crafts Befriending/mentoring Confidence building Learning/training Money – benefits, debt, fuel poverty Housing/adaptations Carers support Dementia support Transport/mobility Advocacy

8. Introduction of a risk stratification tool Case management programme Social prescribing 3 rd sector engagement on supporting people with LTCs Reconfiguration of community nursing services Utilisation of alternative levels of care An enhanced Care Coordination Centre Integrated pathways across health/social care and acute/community Better performance management of community health services What are we doing?

9. Any Questions?