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Pharmacist Maria Bagshaw gives advice to a patient, Durham and Chester-le-Street PCT

Pharmacist Maria Bagshaw gives advice to a patient, Durham and Chester-le-Street PCT

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Home > Long term conditions > Managing Long Term Conditions - NHS Examples

Supporting people with Long Term Conditions
NHS Examples

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Overview 

News Update

Useful Documents

NHS Examples 

US Models

Policy

 Working with Data

 Nursing

Practice Based Commissioning

National Primary Care Development Team (NPDT)

Workforce Change in Long Term Conditions Programme

Events

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NHS Adaptation of US Models

Other NHS Experience

NHS Adaptation of US Models

Matrix Research and Consultancy Ltd was commissioned by the NHS Modernisation Agency to undertake three brief case studies, comparing the different approaches to managing long term conditions taken by United Healthcare (Evercare), Kaiser Permanente and Pfizer Healthcare Solutions.

The report identified the transferable learning for use by healthcare organisations and offers practical information about the process of change.

Click here to download "Managing chronic disease – what to do as a health and social care community - learning from Kaiser, Pfizer and United Healthcare in England"

Evercare 

Implementing the Evercare Programme Interim Report - prepared by Evercare on implementation by nine PCTs

The Evercare programme has been developed in the USA to improve the quality of life for vulnerable older people.  The programme involves developing new ways of working for healthcare professionals and is now being piloted by nine Primary Care Trusts.  The focus is on helping older people to maintain their independence, improve their wellbeing and avoid the need to go into hospitals.  This report provides an interim review of the pilots.  It suggests that the programme and its underlying principles have the potential to improve care in England.

Click here to download Summary of Interim Report

Click here to download the Appendices

Click here to download Success Stories

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NHS/ Evercare Learning Events

Sharing the Learning from the Evercare Project - Part 2 - Thursday 11th March 2004

North Tees PCT Planning and Capacity Model

Bristol and South Gloucestershire PCTs update

Sharing the Learning from the Evercare Project - Thursday 13th November 2003

Earlier Evercare and NHS documents

Adapting the Evercare Programme for the National Health - Background, Principles, Components, Pathway, Consistency with NSF, Benefits, Adapting the Model, Service

Adapting the Evercare Programme for the National Health - Leading Up to Implementation

Adapting the Evercare Programme for the National Health - The Role of the Nurse

Evercare Project in the UK - Evercare project monitoring and assessment 

Evercare Project in the UK - the National Primary Care Research and Development Centre's evaluation

Monitoring the Evercare Project in the UK - Ovations' and NPCRDC evaluation

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Kaiser  

PEC Paper 2 - Learning From Kaiser - Briefing for clinicians

The Kaiser Permanente Approach Bob Crane
Leadership and Culture in Kaiser Sharon Levine
Patients as Partners: Improving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management David Sobel         
"Learning from Kaiser Permanente: a progress report" Professor Chris Ham, Strategy Unit Director
"Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente", British Medical Journal
What PCTs are doing:

Summary, project frameworks, and presentations from each pilot site

Self Care:

The Healthwise Handbook 

 

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Haringey PCT / Pfizer 

 

Team Health: Haringey Health Partnership - Pfizer Collaboration with Haringey PCT               

In February 2004, Pfizer Ltd and Haringey TPCT launched an innovative programme designed to provide individualised support for 600 patients within the London borough suffering from diabetes, heart failure and coronary heart disease.

This document gives a summary of the aims of this 15-month chronic disease pilot programme jointly funded by NatPaCT’s transformational change programme and Pfizer Ltd.

For more information about this pilot programme please contact: Team.Health@haringey.nhs.uk

Team Health: A Vision for Chronic Disease Management in Haringey Gerry Taylor, Deputy Director of Health Improvement, Haringey PCT

This presentation outlines the vision for chronic disease management in Haringey and describe one of the initiatives in the strategy. The strategy incorporates a tiered approach moving from those who can best manage their own care with their GP to those who have the most difficulty in managing their own health.

A key part of this strategy is a partnership project where Haringey TPCT are working with DoH and Pfizer Health Solutions to assess the feasibility and impact of an additional service for those people at the top tier. The programme is based on similar well-evaluated projects in the USA, but this is the first time this specific project will be implemented in the UK. We are therefore carrying out a thorough evaluation of this project and we will highlight some of the issues related to this evaluation. We are just beginning to recruit patients to this project and describe the steps we have taken to get to this stage and when we expect to be able to share the results of this project.

  

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Other NHS Experience 

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North East London Managing Long Term Conditions Collaborative Newsletter - The North East London Managing Long Term Collaborative have started producing newsletters giving news and information about managing long term conditions in North East London.  Further information can also be found on their website - www.nelondon.nhs.uk/ltc

Click here to download January 2005 edition 2 of the newsletter

Click here to download October 2004 edition 1 of the newsletter

Eldercare Project in Cornwall (EPIC) - This project has been in operation since July 2004 and is one of several Modernisation Team projects currently being run in Cornwall to reduce unplanned hospitalisation and increase capacity in community services.  The principle objective of the project is to manage proactively the health of people aged over 75 who have a chronic disease and repeated, unplanned hospital admissions.

Click here to download EPIC First Quarter Evaluation Report

Click here to download Case Studies of EPIC patients

Click here to download EPIC Case Study (in-depth)

Essex SHA Strategic Framework for Case Management of Long Term Conditions - Essex Strategic Health Authority have prepared a strategic framework for the management of long term conditions.  This builds on the Department of Health model in a way which is specifically relevant to Essex SHA, and provides useful additional information for SHAs working on their own strategic frameworks.
Improving management of long term conditions - a case management approach in Bristol and South Gloucestershire - North and South Bristol and South Gloucestershire PCT’s were among a number of pilot sites who implemented a case management approach using the Evercare programme of care for frail elderly members of the population. This document outlines the implementation and evaluation of case management across Bristol and South Gloucestershire and provides information on why the case management approach was seen as a method to improve the quality of care for patients with multiple chronic conditions.
Surrey and Sussex newsletter - Surrey and Sussex SHA have produced a Transforming Chronic Care newsletter. They describe the newsletter as 'for everyone involved in the planning and delivery of all aspects of the programme'.  The newsletter gives useful background on improving care for people with long term conditions and how the Surrey and Sussex healthcare community are going about it.

Transforming Chronic Care Programme - Surrey and Sussex SHA - Presentations from events

Castlefields Health Centre: Approach to case management - Castlefield Health Centre’s approach to case management has excited a lot of interest – and enquiries. They have prepared a detailed account of their work, and powerpoint to answer these – and let them get on with the day job of healthcare:

Castlefields Health Centre Report (word.doc)

Learning from the Castlefields Health Centre - David Colin-Thome & Jayne Penny (Ppt)

Reforming Health Systems: Applying the lessons from Managed Care Conference Report from Hampshire and Isle of Wight PCT Chief Executive Community

 

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