Tailored Support for Long Term Conditions


Offer specific, tailored support for Long Term Conditions, including supportive self-management and shared decision making to develop a self-management plan (with contingency planning) and consider falls and immobility, medicine/polypharmacy and mental health.

Self-management is a person-centred approach in which the individual is empowered and has ownership over the management of their life and conditions. Self-management for the individual includes developing knowledge of their conditions and treatment; management of own medication; managing the effects of illness on physical, emotional and social role and function; reducing health risks; preventative maintenance; and working collaboratively with health and care professionals. Self-management for the professional is the actions by the professional (formal and informal) that assist self-management (self-management support).

The following are examples of what to consider when thinking about supporting people with Long Term Conditions.

  • Involving people, their carers and their families in planning and co-ordinating their own care.
  • Providing support and education for family and volunteer carers, tailored to their level of health literacy.
  • Technology enabled care solutions [TECS] should be considered as part of the menu of options in place for patients to effectively self-manage their long-term condition(s).
  • Personal care budgets and direct payments.
  • A specific, tailored approach with best practice support and care for the following should be undertaken:
    • Falls and Immobility – frail older people have access to services to prevent falls with proactive screening.
    • Polypharmacy
    • Mental health – depression and anxiety

Falls and immobility



The BGS guidelines recommend that GPs review medicines as part of a holistic medical review of older people with frailty.   Therefore, tackling inappropriate polypharmacy is important to both prevent and manage frailty in individuals.  Many tools are available to assess polypharmacy, but none address all aspects of appropriate polypharmacy.  The various aspects to be considered include multimorbidity; safety, efficacy and acceptability of medicines; and the person’s wellbeing, social circumstances and goals.  Therefore, the aim is to reduce polypharmacy if it is possible, especially if the person takes more than ten medicines or has a high-risk of adverse drug reactions. Consider using tools in order to manage inappropriate prescribing and reduce polypharmacy, such as BEERS or STTOP-START.

Mental Health




  • When people are actively involved in their own health and wellbeing, or support others to stay well, it creates value for them and the health and care system in a number of ways.
    • https://www.health.org.uk/sites/health/files/RtVNewApproachesToValue.pdf :
      • On an individual level: The Wanless Review suggested that ‘for every £100 spent on encouraging self-care, around £150 worth of benefits can be delivered in return’.
        • Wanless D. Securing our Future Health: Taking a Long-Term View – The Wanless Review. London: HM Treasury; 2002.
      • Caring for others: Over six million people are involved in informal caring, a quarter of them full time, with the total value estimated at £132bn a year – greater than the NHS budget.
        • Yeandle, S, Buckner L. Valuing Carers 2015: The rising value of carers’ support. Carers UK; 2015. Available from: www.carersuk.org/ for-professionals/policy/policy-library/valuing-carers-2015
  • Personalised care planning leads to improvements in certain indicators of physical and psychological health status, and people’s capability to self-manage their condition when compared to usual care. The effects are not large, but they appear greater when the intervention is more comprehensive, more intensive, and better integrated into routine care.
  • There is evidence of effect from supported self-management (SSM) in long term conditions in older people, though not specifically in frailty.   Supportive Self-Management increases a person’s knowledge about their condition and how to self-care; improves confidence and coping ability; and improves health behaviours, including appropriate use of healthcare.
  • Prescribing medicines which are either inappropriate or are no longer indicated increases adverse drug reactions (ADRs), drug interactions, hospitalisations, costs of care, and may exacerbate frailty (Gnjidic et al., 2012).   Reducing polypharmacy if it is possible, especially if the person takes more than ten medicines or has a high-risk of adverse drug reactions. Consider using tools in order to manage inappropriate prescribing and reduce polypharmacy, such as BEERS or STTOP-START.
  • National guidelines for single long term conditions should be interpreted on an individualised basis; identify medicines or non-pharmacological treatments that might be started as well as stopped; checklists such as the Screening Tool of Older Person’s Prescriptions and Screening Tool to Alert doctors to Right Treatment (STOPP/START) may help meet the person’s desired long term outcomes.

Falls and Immobility


Mental Health (Depression and anxiety)


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