What do we do?
We improved the wellbeing of people with a long-term condition through an intervention that offers stepped care approaches to psychosocial interventions in primary care.
Why do we do it?
The care for people with long term conditions is predominantly delivered by medical and other clinical staff and whose focus is primarily on the physical consequences of the “illness”. Our proposal was informed by our work with people with addictions. Addiction has a relapsing remitting course and is frequently referred to as a long-term condition. The combination of psychosocial interventions (delivered by a multi-disciplinary team of trained practitioners and people with a lived experience) with evidence based clinical care (delivered by medical and other clinical staff) is considered “normal” best practice in this particular long-term condition. We were struck that this is not the case with other long-term conditions where care is predominantly delivered by medical and other clinical staff and whose focus is primarily on the physical consequences of the “illness”.
How do we do it?
People enter our project as part of their long-term condition review or following a new diagnosis in primary care. The intervention is based on their ‘Patient Activation Measure’ score (PAM; an indicator of their ability to self-care). Patients are offered stepped care approaches to psychosocial interventions, ensuring those with the lowest PAM scores are offered the most intensive intervention.
What are our results?
PAM is used to identify patient needs for intervention and to measure success, with an increase in PAM linked to a decrease in healthcare costs. For our latest data, please see our most recent newsletter.
"I was completely blown away with the support you were offering me and my wife after meeting you in clinic, really pleased with you both and this service is a wonderful idea." A Person.
"It's amazing how much you want to help me and how kind and supportive you both are when you talk. I was really looking forward to our chat today." A Person.
"It's a great feeling knowing that someone cares about us and will offer us great advice." A Person.
“We’ve noticed a massive difference since the team started working at our surgery.” A GP
“[Person] is a completely changed person from the one I sent through. They’ve made some big changes and the improvement to their confidence is visible.” A Practice Nurse.