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The NHS and Social Care long term conditions model

  • Last modified date:
    11 January 2007
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.

For example, it reflects learning from US models such as Evercare and Kaiser Permanente. However, the values and structures of the NHS are different. The Model therefore also reflects the strengths of the existing infrastructures and services, particularly in primary and community care, unique to this country. The purpose of the Model is to improve the health and quality of life of those with long term conditions by providing personalised, yet systematic on-going support, based on what works best for people in NHS and social care systems.

The Model will help 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.

The Model provides a structured and consistent approach to help local health and social care partners shape the way they deliver integrated long term care locally. It details the infrastructure available to support better care for those with long term conditions as well as a delivery system designed to match support with patient need.

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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. All health and social care services should begin to adopt this approach. Different interventions should then be used for patients with different degrees of need. The NHS and Social Care Long Term Conditions Model sets out a delivery system that matches care with need. NHS and social care organisations will be familiar with the Kaiser Permanente triangle. The Model builds on this approach

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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 - This 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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