HIGH IMPACT CHANGE 6
Domain: Decision support
Maps to LTC Toolkit Section: Standard 1 - Organisation of Long Term Conditions Management; Standard 3 - Service Design and Multi-disciplinary/Multi-agency Working; Standard 4 - Interdisciplinary Education and Training.
Maps to HEAT Targets: T6 - reduce LTC admissions/bed days for COPD/Diabetes/Asthma/ CHD, T7 - improve quality of healthcare, A7 - reduce A&E rates and waits, T12 - reduce emergency inpatient bed days for 65+.
Maps to Community Care Outcome Themes: User Satisfaction; Support for Carers.
HIGH IMPACT CHANGE 6
Strengthen the contribution of Managed Clinical/Care Networks ( MCNs) to improving care for people with long term conditions.
Rationale
MCNs have a key role in quality improvement, clinical engagement and contributing to planning of services across the whole system ( SEHD (2007) HDL 21). They can evolve to suit local circumstances and in a way which best meets specific need.
- Use MCNs as improvement champions for long term conditions.
- Share learning from patient and carer participation developed by MCNs. The MCN process recommends a four-tiered system of public and patient involvement, these being: Patient involvement, Patient Feedback, Patient and public information, Patient and community participation in services and their planning xxviii.
- Develop integrated patient pathways for long term conditions. Integrated Care Pathways determine locally-agreed, multi-disciplinary practice based on guidelines and evidence, where available, for a specific client group. It forms all or part of the clinical record, documents care given and facilitates the evaluation of outcomes for continuous quality improvement xxix. Change the emphasis from acute episodic care to structured, proactive care using "bundles of care" where clinical evidence supports this.
- Embed evidence-based guidelines in integrated care pathways. Evidence of good practice, guidelines and standards all provide a basis for assessing and reviewing the quality of care xxx.
- Learn from the approach to supporting patient participation e.g. Hearty Voices, Chesty Voices.
- MCNs should engage with the relevant local Voluntary Sector groups to oversee quality of disease specific and generic patient information. This can be provided in a number of ways e.g. leaflets, face-to-face, as part of a support group, web page, peer support group or via telephone help lines. NHS24 provides telephone and internet information which also contains a link to the on-line Health Library xxxi. The Long Term Conditions Alliance for Scotland provides contact details for voluntary sector organizations who can be contacted for disease specific support and information xxxii.