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Supporting People with Long Term Conditions

An NHS and social care model to support local innovation and integration

January 2005

Aim: to improve the health and quality of life of those who have long-term conditions by providing personalised systematic and ongoing support

This document outlines a new model of care, based on a three-tier American model. People with MS may potentially come into all categories of care at different stages of their condition.

Level 1: supported self-care - health professionals will help individuals to develop the knowledge, skills and confidence to care for themselves

Level 2: disease-specific care management - providing people who have a complex single need or multiple conditions with responsive specialist services using multidisciplinary teams and disease-specific protocols, such as the National Service Framework.

Level 3: case management of people with complex disability: requires the identification of very high intensity users of hospital care. In most cases such people will have several long-term conditions.

pyramid model of care on level 1 70-80% of a chronic disease population receive supported self-care. Level 2, high risk patient receive disease-specific care management. Level 3, highly complex patients receive case management

This new model of care requires a new post, that of 'community matron'. 3000 community matrons are to be appointed and their job will be to manage the care of people with very complex needs (level 3 of the model). Unlike previous community nursing jobs, community matrons will have a duty to co-ordinate health and social services to ensure that care is 'joined up' for people.

This document comes with a target of reducing admissions to hospital by 5%, by March 2008.

More information about Supporting People with Long Term Conditions, and a copy of the full document, is available from the Department of Health website.