Specific, tailored support for Long Term Conditions

Including supportive self-management and shared decision making to develop a self-management plan (with contingency planning) optimising falls and immobility, medicine/polypharmacy and mental health.

What work

  • Involve everyone in co-ordinating  support.
  • Offer education tailored to need and literacy.
  • Consider TECS to self-manage long-term condition(s).
  • Consider personal care budgets and direct payments.
  • Offer support and care planning for multiple morbidity and frailty (inline with PCN contract on personal care and anticipatory planning)
  • Screen and advise about falls, encouraging strength and balance training
  • Tackle poly-pharmacy with specialist pharmacists (e.g. SMR in line with PCN contract)
  • Identify and manage depression and anxiety, linking to community services and VCSE
Benefits

  • SSM improves a person’s knowledge about their conditions, coping ability and use of health care.
  • Streamlined management of LTCs.
  • Fewer unnecessary GP appointments.
  • Fewer medicines prescribed, adverse drug reactions and hospitalisation (adverse reactions).
  • Improve medication use (when staff trained in SMR receive training).
  • Reduce the risk of falls.

Evidence summaries

National Voices. Supportive self-management. Summarising the evidence from literature reviews – https://www.nationalvoices.org.uk/sites/default/files/public/publications/supporting_self-management.pdf

Advantage – management of frailty at an individual level: Systematic review – http://advantageja.eu/images/WP6-Managing-frailty-atindividual-level-a-Systematic-Review.pdf

Polypharmacy BEERS – http://patientsafety.pa.gov/ADVISORIES/documents/200512_11.pdf

Impact and Measures

Work in progress

For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures in ‘word version of draft frailty toolkit’ page 51