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Proactive care frameworks for long term conditions

Those with long term conditions, such as diabetes and asthma, are encouraged to actively manage their conditions.  In light of changes made to primary care services due to COVID-19, supporting people with active management may benefit from innovative approaches. We are working with our members to identify opportunities to pilot new ways of working.

Across the healthcare sector there are solutions being developed and implemented and the West of England AHSN is supporting the work of UCLPartners, our fellow Academic Health Science Network (AHSN), who have developed a set of tools to support identification, risk stratification and management of patients post-COVID-19 in primary care.

The objective for this work is to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, while reducing GP workload. This is an opportunity to consider redesigning delivery of care, providing those with long term conditions greater autonomy and support in self management.

What frameworks are available? What support do they offer?

The frameworks include Atrial Fibrillation; high blood pressure; high cholesterol; type 2 diabetes; asthma and COPD.

The frameworks are being implemented by GPs across the country, helping practices to identify who needs priority care, and those whose care can safely be delayed.

The frameworks are comprehensive and include:

  • Comprehensive search tools to risk stratify patients – built for EMIS and SystmOne.
  • Pathways that prioritise patients for follow up, support remote delivery of care, and identify what elements of long-term condition care can be delivered by staff such as Health Care Assistants and link workers.
  • Scripts and protocols to guide Health Care Assistants and others in their consultations.
  • Training for staff to deliver education, self-management support and brief interventions. Training includes health coaching and motivational interviewing.
  • Digital and other resources that support remote management and self-management.

Our approach

The West of England AHSN is supporting this project by initially working with a small number of surgeries to pilot the frameworks for asthma and type 2 diabetes. The implementation resources available for participating practices include access to motivational coaching, facilitation of team meetings to discuss project goals and workforce changes and signposting to clinical training and resources.

By sharing learning between these pilot sites and across the AHSN Network, we are able to understand the requirements and success criteria for implementing the frameworks more widely.

If you are interested in support from the West of England AHSN to access these frameworks please contact:

What other resources are available?

Additional tools and approaches are available to support patients with long term conditions.

This page will be updated as the project develops, so please do check back for the latest opportunities and updates.

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