Multiple Long Term Conditions Project

What do we hope to achieve?

We are exploring how to bring together professionals across the system to work as a team to improve the care experience of people with Multiple Long Term Conditions.   We hope this will provide better organised care around the patient reducing multiple appointments for patients at their practice and hospital.

Why are we doing this?

  • To improve medication management and care planning
  • To improve access to relevant clinicians and professionals
  • To reduce duplication of services reducing the need for patients to repeat their story

How will we get there?

We will

  1. IDENTIFY PATIENTS with multiple problems and aligning them with care professionals relevant to their care using information from their GP practice and hospital records.
  2. INFORM PATIENTS who have been selected and ask if they are happy to participate in this new approach. This new approach may propose that the patient no longer need to attend a hospital appointment  or see one specialist rather than two.  From the options proposed,  patients will be able to agree their care with the joined up team.
  3. UNDERSTAND AND DISCUSS the patients’ health and care needs. Team members will review the patients GP and hospital records to discuss the patients’ health and care. This will involve informing the team about the patient’s medication, planned tests, appointments and procedures.
  4. CARE PLAN. Once we have organised all the information from the GP and different clinics, we will invite patients to an appointment with a bespoke team. This appointment may be in person or online, and it may include a family member or carer depending on the patient’s wishes and situation. At this appointment, all care will be discussed and planned and contact agreed, who the patient can access if they have any queries or concerns, and may liaise with the patients GP on their behalf.
  5. ONGOING CARE PLANNING. The initial appointment will inform the ongoing care is and when the patient is next to be reviewed. A care coordinator will be responsible for organising this care and follow up appointments.

Who could be involved in care planning?

  • Primary care team
    • GP, link worker, care coordinator, practice pharmacist
  • Hospital team
    • Geriatrics, diabetes, renal, cardiology and respiratory specialist links
  • Community, mental health and social care team
    • Community matron, social worker and community psychiatric nurse

Project Timeline

The test will take place between November 2021 and November 2022.

More details and evaluation to follow.