Director of Public Health Annual Report 2012 [pdf] - Stoke-on-Trent ...

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EVIDENCE: Research Research focuses on the complex mix <strong>of</strong> factors that influence the development <strong>of</strong> long-term conditions as well as finding better ways to diagnose and treat. It is equally important that research occurs locally, taking into account local cultural, social and healthcare settings. Local research, as illustrated in the case study, reviewed the impact <strong>of</strong> ‘pairs’ <strong>of</strong> LTCs on hospital admissions 30 . Case Study Local Research Keele University is developing a risk stratification tool to identify ‘Frail Elderly’ people using information from primary care. It aims to allow clinical staff to identify and proactively manage ‘Frail Elderly’ patients, avoiding some inappropriate uses <strong>of</strong> urgent care services. People are defined as ‘Frail’ when they have an increased likelihood for death, disability, dependency, falls, and need for long-term care. Admission prediction and <strong>of</strong>fering preventive care can improve the health status <strong>of</strong> these high-risk patients. This may also reduce unplanned admissions making overall savings for the NHS. The tool will initially be applied to patients in nursing and care homes. Mosaic pr<strong>of</strong>iles <strong>of</strong> groups are also used to understand differing levels <strong>of</strong> hospital admissions and costs among people who have some LTCs. A local study looking at people with ‘pairs’ <strong>of</strong> LTCs, found that some combinations <strong>of</strong> LTCs had a higher likelihood <strong>of</strong> hospital admission that others. Over one in three (67%) <strong>of</strong> individuals with both chronic heart failure and chronic kidney disease had at least one A&E episode; four in five (80%) <strong>of</strong> this group had a hospital admission. In comparison, over one in three (37%) individuals with hypertension and diabetes had at least one A&E episode; over two in five (44%) a hospital admission. The study also found higher costs associated with some LTC combinations. More recent research 31 focusing on primary care suggests the need to shift the focus from individual disease quality frameworks, particularly for patients with multimorbidity, to those using a range <strong>of</strong> tools to integrate and prioritise care pathways. The different evidencebased elements that contribute to the overall identification, management and improvement in care <strong>of</strong> people with long-term conditions naturally work most effectively when combined in a seamless model <strong>of</strong> care such as the one in figure 15. Query What is Mosaic Mosaic is a classification system that uses individual postcode level data to create a picture <strong>of</strong> local neighbourhoods in regards to socioeconomic, lifestyle, cultural and behavioural characteristics. It is designed to describe different types <strong>of</strong> people living in particular areas, what their specific needs are and how best to engage them. 52 | P a g e
Figure 15 Long-term conditions model <strong>of</strong> care INFRASTRUCTURE DELIVERY OUTCOMES Community Resources Prevention Early Diagnosis Improved Care Reduced Risk Prevalence Modelling Risk Stratification Integrated <strong>Health</strong> and Social Care Teams Proactive Care Team <strong>Health</strong> and Social Care Environment Case management Empowerment Research Personalisation Telehealth Medicines Management Source: Adapted from The NHS and Social Care Model (2005) 53 | P a g e
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Living Well, Staying Well: Long-Ter
Page 3 and 4: 2012 Introduction
Page 5 and 6: Introduction Last year’s annual r
Page 7 and 8: 5 | P a g e
Page 9 and 10: Fair Society, Health</stron
Page 11 and 12: 9 | P a g e
Page 13 and 14: Years of life The
Page 15 and 16: Years of life Figu
Page 17 and 18: Map 2 Mortality rates from all caus
Page 19 and 20: Map 4 Mortality rates from cancer (
Page 21 and 22: Map 6 Mortality rates from circulat
Page 23 and 24: Map 8 Mortality rates from all resp
Page 25 and 26: Mortality rate per 1,000 live birth
Page 27 and 28: Table 2 Rankings of</strong
Page 29 and 30: The lifestyles of
Page 31 and 32: The percentage of
Page 33 and 34: Access to treatment has improved si
Page 35 and 36: Health and lifesty
Page 37 and 38: Ten Things You Need To Know About L
Page 39 and 40: Currently, three out of</st
Page 41 and 42: Concerns about stigma that surround
Page 43 and 44: Number Living with Long-term Condit
Page 45 and 46: Map 10 Percentage of</stron
Page 47 and 48: Box 4: People with multimorbidity w
Page 49 and 50: Evidence based approach to managing
Page 51 and 52: This is clearly illustrated in figu
Page 53: EVIDENCE: Risk stratification Risk
Page 59 and 60: Figure 16 shows that a child born w
Page 61 and 62: Long-term conditions chapter LTCs a
Page 63 and 64: Progress of recomm
Page 65 and 66: Fair Society, Health</stron
Page 67 and 68: Appendix 2 Mortality and hospital a
Page 73 and 74: Appendix 5 ward Mortality and hospi
Page 75 and 76: Appendix 6 Rankings of</str
Page 77 and 78: Appendix 7 Rankings of</str
Page 81 and 82: 15 Department of <
Page 83 and 84: Here are 5 evidence based ways to h
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