Policy The NHS Improvement Plan: Section 2: Chapter 3: Supporting people with long-term conditions to live healthy lives
 Supporting People with Long Term Conditions, an NHS and Social Care Model to support local innovation and integration
Self Care - A Real Choice: Self Care Support - A Practical Option
Publications  Action on Neurology: Improving Neurology Services - A Practical Guide
This guide aims to help those implementing the new National Service Framework for Long Term Conditions, which focuses on long term neurological conditions. Leaflet series - What's in it for me? The Long Term Conditions team have produced a series of leaflets about the benefits of long term conditions work to different professsional groups. These leaflets are available to download below: Managing Long Term Conditions: What's in it for GPs? Managing Long Term Conditions - What's in it for Pharmacists?
From Chaos to Care: the promise of team-based medicine - David Lawrence, Perseus Books, 2002
Report by Matrix Research - comparison of approaches to Managing Long Terms Conditions
"Managing chronic disease – what to do as a health and social care community - learning from Kaiser, Pfizer and United Healthcare in England" - Matrix Research and Consultancy Ltd. Evaluative Report
Chronic Disease Compendium of Information
Implementing the Evercare Programme Interim Report - prepared by Evercare on implementation by nine PCTs Implementing the Evercare Programme Interim Report Summary of the Interim Report
Adapting the Evercare Programme for the National Health - Background, Principles, Components, Pathway, Consistency with NSF, Benefits, Adapting the Model, Service
Adapting the Evercare Programme for the National Health - Leading Up to Implementation
Adapting the Evercare Programme for the National Health - The Role of the Nurse
Evercare Project in the UK - Evercare project monitoring and assessment
Evercare Project in the UK - the National Primary Care Research and Development Centre's evaluation
Monitoring the Evercare Project in the UK - Ovations' and NPCRDC evaluation
PEC Paper 2 - Learning From Kaiser - Briefing for clinicians
The Kaiser Permanente Approach Bob Crane
Leadership and Culture in Kaiser Sharon Levine
Patients as Partners: Improving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management David Sobel
"Learning from Kaiser Permanente: a progress report"Professor Chris Ham, Strategy Unit Director
"Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente", British Medical Journal.
The Healthwise Handbook
Chronic Care Management:Key Principles of Case Management
Pyramid of Care and potential of community pharmacy
Roles of the Advanced Primary Nurse
PEC Paper 4 United Healthcare / Evercare
back to top Presentations Improving Management of Long Term Conditions - Presentation by Chris Dowse (Powerpoint) Improving Management of Long Term Conditions - A Powerpoint Presentation by Chris Dowse (zip.file)
"The Nursing Perspective on Chronic Disease Management" - Presentation by Sally Bassett, Nurse Advisor to LTC Team from "Developing the Role of the Community Matron" conference, 27th October 2004
A National Perspective for the Evercare programme Role of the APN
Powerpoint presentation version of the Chronic Disease Compendium of Information
MA Improvement Summit 2/3 November 2004 Chris Dowse, Modernisation Agency Programme Lead, Long Term Conditions and Victor Newman, Knowledge Works - Improving the Management of Long Term Conditions
NHS Confederation 24 June 2004 Gary Belfield, Head of Primary Care, Department of Health Chris Dowse, Modernisation Agency Programme Lead, Chronic Disease Management
Case Management Roadshows, June 3, 4, 9, 11 & 16 2004 Welcome Presentation, Gary Belfield Head of Primary Care Learning from the Castlefields Health Centre - David Colin-Thome & Jayne Penny Primary Care Contracting - a Lever for Change - Dr Philip Leech Workshops Advancing the NHS Plan - The Evercare Programme Evercare - identifying the right patients – extracting and analysing the data Evercare:Identifying the right patients – extracting and analysing the data (Gerald Lutgen) A National Perspective for the Evercare programme Role of the APN Roadshow pm Commissioning for Chronic Illness Ideas for the future of NHS commissioning Noel Plumridge and Anita Maynard SE London Health Authority June 2004 The National Primary Care Contracting Collaborative – Jacquie White Commissioning for Chronic Ilness – Noel Plumridge & Anita Maynard COPD & Diabetes in Primary Care – Barbara Edwards Commissioning for Chronic Disease Management, Roy Paterson, NatPaCT National Primary Care Collaborative Phase III Wave One Chronic Disease Management - David Latham Assistant Collaborative Director Plenary Session – Gary Belfield
National CDM Event 18 May 2004 Full Conference Report Managing Chronic Conditions: An International Perspective - Rafael Bengoa, WHO Chronic Care In America - Gerard Anderson Chronic Disease Management and the UK - Looking to the Future - Sue Roberts, National Diabetes Czar, Disease Management or Life Management? - Harry Cayton, Director of Public and Patient Involvement Evercare Programme: Chronic Disease Management and Redesign of Primary and Community Services - Alistair Howie, Chief Executive, Walsall Team Health: A Vision for Chronic Disease Management in Haringey -Gerry Taylor, Deputy Director of Health Improvement, Haringey PCT
Learning from Kaiser 4 November 2003 Summary of John Reid's speech The Kaiser Permanente Approach Bob Crane Leadership and Culture in Kaiser Sharon Levine Patients as Partners: Improving Health and Cost Outcomes with Self-Care and Chronic Disease Self-Management David Sobel Online recordings of these presentations
back to top Useful Examples North East London Managing Long Term Conditions Collaborative Newsletter - The North East London Managing Long Term Collaborative have started producing newsletters giving news and information about managing long term conditions in North East London. Further information can also be found on their website - www.nelondon.nhs.uk/ltc Click here to download January 2005 edition 2 of the newsletter Click here to download October 2004 edition 1 of the newsletter
Eldercare Project in Cornwall (EPIC) - This project has been in operation since July 2004 and is one of several Modernisation Team projects currently being run in Cornwall to reduce unplanned hospitalisation and increase capacity in community services. The principle objective of the project is to manage proactively the health of people aged over 75 who have a chronic disease and repeated, unplanned hospital admissions. Click here to download EPIC First Quarter Evaluation Report Click here to download Case Studies of EPIC patients Click here to download EPIC Case Study (in-depth)
Essex SHA Strategic Framework for Case Management of Long Term Conditions - Essex Strategic Health Authority have prepared a strategic framework for the management of long term conditions. This builds on the Department of Health model in a way which is specifically relevant to Essex SHA, and provides useful additional information for SHAs working on their own strategic frameworks.
Improving management of long term conditions - a case management approach in Bristol and South Gloucestershire - North and South Bristol and South Gloucestershire PCT’s were among a number of pilot sites who implemented a case management approach using
Surrey and Sussex newsletter - Surrey and Sussex SHA have produced a Transforming Chronic Care newsletter. They describe the newsletter as 'for everyone involved in the planning and delivery of all aspects of the programme'. The newsletter gives useful background on improving care for people with long term conditions and how the Surrey and Sussex healthcare community are going about it.
Transforming Chronic Care Programme - Surrey and Sussex SHA - Presentations from events
Castlefields Health Centre: Approach to case management - Castlefield Health Centre’s approach to case management has excited a lot of interest – and enquiries. They have prepared a detailed account of their work, and powerpoint to answer these – and let them get on with the day job of healthcare: Castlefields Health Centre Report (word.doc) Learning from the Castlefields Health Centre - David Colin-Thome & Jayne Penny (Ppt)
Reforming Health Systems: Applying the lessons from Managed Care Conference Report from Hampshire and Isle of Wight PCT Chief Executive Community
back to top Tools and Templates A 'rough guide' to co-designing services for Long Term Conditions
The Engaging Communities Learning Network have developed this 'rough guide' from a series of workshops held early in 2005 which looked at making the connections between long term conditions and patient and public involvement.
Self-Assessment Tool for Managing Long Term Conditions The Long Term Conditions team have produced a Self Assessment Tool to help health and social care organisation and communities. The self-assessment tool will identify areas of progress within LTC, key gaps, ‘quick wins’ and longer-term goals.
Evercare:Identifying the right patients – extracting and analysing the data (Gerald Lutgen)
Chronic Disease Management: Population Management (Pyramid)
back to top Useful Links
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