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The Long Term Conditions Agenda Networks/multi-disciplinary teams


The Long Term Conditions Agenda Networks/multi-disciplinary teams Claire Whittington Commissioning Directorate Aims Overall context Outline emerging proposals ... – PowerPoint PPT presentation

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Title: The Long Term Conditions Agenda Networks/multi-disciplinary teams

The Long Term Conditions AgendaNetworks/multi-di
sciplinary teams
  • Claire Whittington
  • Commissioning Directorate

  • Overall context
  • Outline emerging proposals
  • Consider how multi-disciplinary teams/networks
    supports the delivery of LTC

The New Clinical Paradigm
  • While the global disease burden has been
    shifting towards chronic conditions, health
    systems have not evolved to meet this changing
    demand. Care is fragmented, focused on acute and
    emergent symptoms, and often provided without the
    benefit of complete medical information WHO
    (2002) 1

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Range of White Paper LTC commitments
  • Bigger emphasis on self care and integration
  • Requirement for multidisciplinary teams/networks
  • Universal case management for VHIUs
  • Personal Health and Care Plans
  • Whole System LTC Demonstrators
  • 24/7 single point of contact for people with
    complex needs

Direction of travel
  • Increasing emphasis on care outside hospital
  • Intelligent and Agile Commissioning
  • Patient and Client centred care
  • Information and technology as powerful enablers
  • Integration - key

international research suggests that integration
is most needed and works best when it focuses on
a specifiable group of people with complex needs,
and where the system is clear and readily
understood by service users (and preferably
designed with them as full partners). -
Integrated Care a Guide, Integrated Care Network
White Paper commitment
  • By 2008 we expect all PCTs and local authorities
    to have established joint health and social care
    managed networks and/or teams to support those
    with long term conditions who have the most
    complex needs.

Elements of integration (WHO)
  • Horizontal integration linking similar levels of
  • Vertical integration linking different levels of
  • Continuity of care user perspective ideal
  • Integrated care encompassing technological,
    managerial and economic aspects of service

Why focus on networks and teams ?
  • Principle of integrated teams been around for a
    long time
  • Networks to coordinate development of a service
    more recent
  • Proven that both can deliver benefit
  • YET
  • Establishment of teams fragmented
  • Networks not wide spread
  • Concept unclear
  • Expectations of what can be delivered through
    both confused

How to encourage wide scale development
  • Best practice guidance
  • Recognise that teams and networks are distinct
    but complementary implement in parallel
  • Vision for how can be used locally
  • Consider barriers and how can overcome

  • Managed network involving clinicians, users,
    managers across health and social care
  • Role identify needs of LTC population, look at
    care pathways to deliver optimal care and inform
    commissioning decisions
  • Led by Senior Officers/Directors of PCT/LA
  • All need to be accountable so governance critical

Patient Care Team (Starfield)
  • a group of diverse clinicians who
    communicate with each other regularly about care
    of a defined group of patients and participate in
    that care

Multi-disciplinary teams
  • Bring together individuals who plan and deliver
    care across organisational boundaries to
    particular groups of users
  • Combined potential of
  • Individual professions
  • Organisations
  • Third sector partners
  • Benefit
  • More eyes and ears
  • Insights of different bodies of knowledge
  • Comprehensive, holistic view of users needs
  • Wider range of skills
  • Increased range and quality of services available
    integrated and seamless
  • Effect
  • Improved health outcomes
  • Reduced costs

What makes up a team ?
  • Different team components/different user needs
  • Practice/multiple practice
  • Practice/specialist acute care
  • Practice/specialist acute care/social
    care/housing/voluntary sector (significant
  • Mix of skilled clinicians/educators with clinical
    and self care support skills and public health

What makes up a team (2)
  • Not prescriptive
  • Consider different skills of
  • GPs
  • Practice nurse/specialist nurse/community matron
  • Medical specialists
  • Pharmacists
  • Social workers
  • Lay health workers
  • OTs
  • psychiatrists
  • Voluntary sector
  • Others
  • Based on needs of user

  • Management structures
  • Breaking down professional silos
  • Training and preparation
  • Information sharing and communication
  • Insufficient nurturing of teams

Key factors for success
  • Shared core roles, goals and values
  • Understanding and respect for competencies of
    other team members
  • Need to learn from other disciplines and respect
    their different views and perspectives
  • Individual team members may need to reassess
    exclusive claims to specialist knowledge and
  • Team development training
  • Integrated management systems
  • Formulation of operational policies

Effectiveness of team care (Wagner)
  • Population based care
  • Care plans
  • Self care support
  • Sustained follow up
  • Also supports many of White Paper commitments
  • Also need to consider 24/7

An opportunity
  • How to provide a seamless and holistic service
  • Redesign user centred services
  • Significant role people with long term
  • Huge potential
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