Long Term Condition Management
Serco offers an integrated solution to Long Term Condition Management (LTCM), based on our Informatics system working in conjunction with community matrons.
The programme has delivered on other government objectives including:
- Providing care closer to patient's homes
- Ensuring patients and their family/carers have more control over their own care
- Facilitating closer working between health and social care
- Providing better management information to ensure continuing improvement of services
Patients' lives have been transformed, with many patients commenting on the peace of mind and reassurance that the service gives them. One patient said "Knowing that I'm being checked at regular intervals, puts my mind at rest, and the community matron can tell by just seeing me if anything is wrong, and I can talk to her with my concerns before anything gets too bad."
The Long Term Condition Management video sets out how this has been used to improve care for the people of Newham.
The programme has been evaluated and this has revealed some outstanding results:
- The number of emergency hospital admissions reduced by 26% (with reductions of up to 40% by some of the more experienced Community Matrons)
- A&E attendances fell by 16%
- Non-routine contacts with primary care (GP visits, appointments with practice nurses, etc) fell by up to 57%.
Serco Health are also working in partnership with Sheffield Primary Care Trust, Sheffield Health and Social Care NHS Foundation Trust, and Sheffield Teaching Hospitals NHS Foundation Trust to deliver intermediate care services to the people of Sheffield. The consortium is introducing innovative models of intermediate care, using assistive technology to place the patient and their carers at the heart of the service, enabling people to be cared for at home whenever possible.