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Long term conditions model
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Last modified date:24 April 2008
The NHS and Social Care Long Term Conditions Model builds on the wealth of local and international experiences and innovations to improve the health and quality of life of those with long term conditions.
The Model:
- Provides personalised, yet systematic on-going support, based on what works best for people in NHS and social care systems
- Will help to ensure effective joint working between all those involved in delivering care - including secondary care, ambulance trusts, social care and voluntary and community organisations - so patients experience a seamless journey through the health and social care systems
- Provides a structured and consistent approach to help local health and social care partners shape the way they deliver integrated long term care locally
The recommended route to deliver a systematic approach is to:
- Utilise multi-professional teams and integrated patient pathways to ensure closer integration between health and social care
- Match care with need, using different interventions for patients with different degrees of need
Level 3: Case management
Requires the identification of the very high intensity users of unplanned secondary care. Care for these patients is to be managed using a community matron or other professional using a case management approach, to anticipate, co-ordinate and join up health and social care.
Level 2: Disease-specific care management
Involves providing people who have a 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.
Level 1: Supported self care
Collaboratively helping individuals and their carers to develop the knowledge, skills and confidence to care for themselves and their condition effectively.
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