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Enhanced Primary and Community Care programme

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From Steve Grange, Programme Director

One of the biggest challenges for Staffordshire and Stoke-on-Trent is that services are fragmented, and there is variation in term of outcomes for patients who live with a long-term condition (LTC). It is recognised that patients with well-managed LTCs are less likely to need non-elective care, are more likely to manage their own health, including their mental health, and will have a greater quality of life.

LTCs fall under the banner of EPCC and within this programme of work we aim to improve:

  • Diagnosis rates for chronic obstructive pulmonary disease (COPD), hypertension, coronary heart disease (CHD), diabetes and also Atrial Fibrillation (AF)
  • Uptake of flu vaccinations for patients with COPD, CHD and diabetes
  • Blood pressure monitoring for patients with CHD, hypertension, diabetes and peripheral arterial disease
  • Smoking cessation and support
  • Ongoing management of COPD patients including FEV1 tests, annual reviews and breathlessness assessments
  • The number of AF patients who are treated with anticoagulation drug therapy
  • Ongoing management of diabetes patients including monitoring of cholesterol, blood glucose, blood pressure and adherence to the NICE Nine Processes of Care for Diabetes
  • Non-elective admission rates and bed days for respiratory patients.

Primary Care Networks (PCNs) and Integrated Care Teams (ICTs) encourage health professionals to work together to minimise workforce problems, benefit from economies of scale, and work across primary, community, acute and social care boundaries to join up pathways for their patients. Prevention, alongside social prescribing, within PCNs sits at heart of the LTC pathways and will signpost and encourage self-care opportunities for the patient to take back the choice and control of their condition.