A DIGITAL VISION TO MAXIMISE SELF CARE FOR PATIENTS WITH LONG TERM CONDITIONS

Based on best practice both here and abroad, the evidence based LTC generic care pathway is built around 3 key drivers; risk profiling, integrated care teams and maximising self care. The LTC QIPP workstream has been working to implement this model across the country for 18 months and has identified a number of projects that will support the delivery of these drivers.

There is huge potential for digital services to support health and social care teams to implement these drivers especially around self care, shared decision making and transferring knowledge and power to patients. Therefore, the LTC workstream has been working closely with the Digital Technology QIPP team to develop a ‘digital vision’ for people living with long term conditions.

The Vision

A fundamental shift in care for people living with long term conditions:

•       From: Condition-Specific face to face management for LTC patients with limited use of digital technology.  

•       To: A locally driven digitally enabled holistic approach to health and wellbeing for patients and their carers, maximising self care and supporting the systematic transfer of power and knowledge to patients. A patient-centred care planning approach and shared management of conditions through the patient’s channel of choice.

The key features of a holistic digital service:

The delivery of such services will be at a local or regional level and will build on any current digital services that are available. Some of the features required to provide a holistic service are described below, (these will build up gradually over time in each region).

•       Access to online medical records (through GP practice website)

•       Personalised care planning service (through a localised service) that will allow LTC and End of Life patients and carers to be active partners in their care

•       Sharing of electronic care plans with relevant care givers (subject to patient consent)

•       Personalised and targeted information (based on patient preferences and care planning goals/actions) including local services, e-learning materials and online self assessment tools.

•       Secure communication between patient and care team

•       Transactional services such as appointment booking delivered through local clinical systems

•       Reminders and alerting facilities to support medication management and other scheduled activities

•       Patient / carer feedback on care and services (this will also inform the commissioning process)

•       Telehealth / telecare / telemedicine

•       Multi-channel services, enabling patients to select the most convenient access channel e.g. internet, smartphone and Digital Interactive TV

The delivery model and the national enablers

The national vision is NOT about developing a central electronic care plan or a national digital programme; the delivery of all these digital services will be driven from a local level. The national role is to support local development and accelerate delivery of this vision through the creation of a number of technical national enablers (e.g. information standards, interoperability specifications and access management).