Long-Term Conditions Pathways

Long-Term Condition (LTC) patients are growing in demand and severity, and some have multi-morbidities. There is a need for more responsive and coherent care and treatments need to be devised through collaboration with partners. The BHR LTC education programme was established in order to support both clinical and non-clinical workforce, for different tiered patients to manage these conditions in the most effective way.

Each LTC condition has been divided into three cohorts:

1) Tier 1 is for those patients at the early onset of their LTC experience and can benefit from light touch interventions, particularly looking at lifestyle changes and decisions. The target workforce for these T1 webinars is:
Social prescribers / Care coordinators / Health & Wellbeing coaches / Social Care staff / Voluntary and Community Sector staff / Any other workforce who has service users with early onset LTC and can benefit from light touch interventions, particularly looking at lifestyle changes.

2) Tier 2 is for those patients with more established LTCs but responding well to interventions. The target workforce for T2 webinars is main grade clinicians – GPs, nurses, pharmacists and other Allied Health Professionals.

3) Tier 3 is for those patients with complex conditions or those not responding to/complying with interventions. The target workforce for these webinars is senior clinicians – GPs and advanced clinical practitioners.

Asthma

Cardiovascular disease

Chronic kidney disease

Diabetes

Hypertension

Immunisations

Osteoporosis

Pulmonary disease

Remote monitoring

Sickle cell disease