The Long Term Conditions Collaborative ( LTCC) has been designed and developed by the Improvement and Support Team ( IST) and NHS Boards in support of Better Health, Better Care as part of a new and ambitious improvement agenda. We are working with partnership with NHS Scotland, local authorities and the voluntary sector to support the delivery of key national targets.
These are:
- By 2010/11, reduce the emergency inpatient bed days for people aged 65 and over, by 10% compared with 2004/05.
- Achieve agreed reductions in the rates of hospital admissions and bed days of patients with primary diagnosis of Chronic Obstructive Pulmonary Disease, Asthma, Diabetes or Coronary Heart Disease from 2006/07 to 2010/11.
- Achieve improvement in the quality of the healthcare experience.
- Increase the percentage of people with complex needs who are cared for at home.
- Achieve agreed reductions in the rates of attendance at A&E, from the end of 2007/08 to end 2010/11.
'Delivering sustainable improvements in patient-centred services for people with long term conditions.'
High Impact Changes - Drivers for Change
The High Impact Changes ( HICs) have been designed to support the delivery of these targets and have a big impact on the way people with long term conditions manage and experience their care. Each HIC comes with a bundle of improvement actions, which are intended to provide some 'bite-sized' solutions to what can appear to be a complex challenge.
The High Impact Changes are:
1. To empower people living with long term conditions, their carers and the voluntary sector to be full partners in planning, improving quality and enhancing the experience of care.
2. To support people with long term conditions and their unpaid carers to be involved in person-centred care planning.
3. To commission peer support groups for people with long term conditions and their carers and provide relevant, accessible information.
4. To train staff to have the right knowledge, skills and approach to long term conditions care.
5. To provide better, local and faster access to services for long term conditions.
6. To strengthen the contribution of Managed Clinical/Care Networks ( MCNs) to improving care for people with long term conditions.
7. To have information systems that support registration, recall and review for people with multiple conditions and support data sharing.
How will we support the implementation of these changes?
- Provide the knowledge and skills to help staff improve their systems and processes.
- Provide the right tools and methodology through our training events.
- Provide support and advice through our regional teams.
- Provide funding to free up clinicians and practitioners to design and deliver change and improvement.
2008 - 2009 - We will support delivery of:
- High Impact Changes and Improvement Action bundles
- Measures for Improvement and definitions
- Long Term Conditions Community of Practice
- Regional and national learning events
- PDSA cycles
- 14 Day Challenges
What are our long term aims?
- Better patient experience
- Dramatically improved, holistic care
- Safer, seamless transitions of care
- Better communication - amongst health professionals, community and voluntary sector, and local authority partners to provide the best care possible
- Improved pathways and systems - tailored to needs
- Best use of current resources
'People working together to actively share, learn and apply to ultimately achieve best practice' - Local programme manager
The Collaborative has three workstreams: self management, condition management and complex care.
Shared Space:
The LTCC has a secure virtual workspace area within Shared Space in the e-Library to enable:
- The sharing of documents, case studies, conference abstracts and posters.
- Links and signposting to good practice and other resources available.
- Online discussions and networking.
- Updates on events and news pertinent to long term conditions.
In order to use Shared Space, you will need to obtain an Athens password. This can be achieved through the following link: www.elib.scot.nhs.uk/SharedSpace/ist/Pages/Index.aspx?ContainerID=143850
More Information:
For more information on the LTCC please visit our website at: www.scotland.gov.uk/Topics/Health/NHS-Scotland/Delivery-Improvement/1835/210369
To access our Toolkit, please visit: http://member.goodpractice.net/ContinuousImprovementToolkit/Welcome.gp
Susan Bishop
National Programme Manager
Susan.bishop2@scotland.gsi.gov.uk
Sara Porthouse
National Programme Officer
Sara.porthouse@scotland.gsi.gov.uk