Integrated care pathway empowers people to manage their long term condition at home


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This case study describes how Leicester City CCG launched a new care pathway to better support people with a long term condition to manage their health at home, supported by new community-based services. 

The new model combines shared decision making using a new patient decision aid, health coaching and telehealth monitoring. During a six-month pilot with 50 patients, the unscheduled admission rate fell from an average of 3.29 per person to 1.24 and the service delivered cost savings of £353,000 and a significantly improved patient experience.

In addition to describing the process used and some of the associated challenges, the case study includes a number of top tips:

  • engage with patients from the start:Taking time to introduce and explain the new service, and to discuss what would be different from the current service, was very important in obtaining patient consent and securing full participation.
  • Clinical leadership is key: Clinical leadership was essential in driving the project and in establishing credibility with GPs and nurses.
  • identify the patients who will benefit the most: Although the initial cohort of patients were the most vulnerable, they were too poorly to benefit from the service. Key to success was identifying the patients who would get the most from empowerment and self-management, rather than simply swapping their dependency from clinicians in hospital to clinicians in the community.
  • Think about the iT: A key learning point from the project was that an integrated and accessible IT system, connecting primary, acute, community and social care, is essential for supporting integration.

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