Our long-term conditions programme provides support to health and social care teams to improve care for people living with long-term health conditions and those who are at risk of falls. This year we created a new Long Term Conditions Section on our website. As well as information for people living with long term conditions, it includes information for families and carers.
Supporting people living with Chronic Obstructive Pulmonary Disease (COPD)
Edinburgh’s Community Respiratory Hub provides support to people living with Chronic Obstructive Pulmonary Disease (COPD) who are at high risk of hospital admission. During 2020, the Community Respiratory Team assessed 414 people, who were at immediate high risk of hospital admission because of an acute exacerbation of their COPD. Following assessment, the Community Respiratory Team supported 84% of these people to be safely cared for at home, avoiding hospital admission.
In place of our Pulmonary Rehabilitation classes we offered support for those already engaged, or with completed assessments, to use the myCOPD app. The myCOPD app supports people living with COPD to better manage their condition and improve their outcomes. Telephone coaching and group virtual classes were also offered.
Supporting people at risk of falls
By proactively providing support on how people can stay active and steady on their feet, we can either prevent falls happening or improve the way a fall is managed. Working in partnership with the British Red Cross, 250 ‘Staying Active’ packs were distributed via community nurses and physiotherapists to people who were shielding and at risk of falls during the Covid-19 pandemic and 600 Staying Active leaflets were distributed via the City of Edinburgh Council’s shielding phone line.
Anticipatory care planning
Anticipatory care planning (ACP) is a person-centred, proactive, ‘thinking ahead’ approach, with health and care professionals working with individuals, carers and their families to make informed choices about their care and support. Key Information Summaries, which contain anticipatory care planning information such as care preferences taken securely from the GP electronic record, are shared with health professionals if people need urgent care.
During the pandemic, we focussed on supporting practitioners to have care planning conversations and create plans for people living with long term conditions who were most at risk of Covid-19. The number of Key Information Summaries for people living in Edinburgh has increased from 66,966 in March 2020 to 237,372 in March 2021 (254% increase).
To support the creation of Covid-19 relevant ACPs, all care homes for older people and GP practices in Edinburgh were provided with a Covid-19 revised edition of the 7 steps to ACP for care homes. We also continue to work with VOCAL and the Edinburgh Carer Support Team to support carers through care planning conversations.
Self management supports people living with long term conditions to be actively involved in their own health and wellbeing as the leading partner in their care. In partnership with Lothian Centre for Inclusive Living, we successfully tested and adopted a new Self Management Support Worker post during the pandemic. This role will help people with long term conditions develop self-management skills and connections with community support.
We also launched the Edinburgh Self Management Network during Self Management week (28th September-2nd October 2020). This online network supports practitioners to share good practice, find out about services, activities and events, and innovate self-management approaches. This network has created a self-management toolkit, including the Edinburgh Connect Here Directory of City Wide Community Resources, which contains over 2,000 community resources to help people live with their long term condition.
We also accelerated the rollout of the telemonitoring programme to support diagnosis and self-care of hypertension and reduce the requirement for patients to attend health centres to have their blood pressure checked. People using this approach require one less consultation per annum on average, a 25% reduction in face to face contacts with a clinician. This was particularly important for patients who were shielding over the last year, many of whom have cardiovascular disease.
Between April 2020 and March 2021, 1,561 new patients have used the Florence Scale Up Blood Pressure programme in Edinburgh to remotely monitor their blood pressure and adhere to their shared management plan. In total, 4,014 patients in Edinburgh from across 60 GP practices use this programme.