Long Term Conditions Collaborative: Improving Care Pathways

A resource to improve care pathways for those with long term conditions.


Improvement Actions:

  • Provide telehealth and telecare support for self management
  • Offer telehealth solutions
  • Provide telecare support


Telehealth is the provision of healthcare at a distance using telephony and broadband digital technologies to support videoconferencing and remote physiological monitoring. Telecare is the use of assistive technologies to support those in a home or community environment who would otherwise be at increased risk of coming to harm from a range of causes. Clinical involvement is not necessarily part of that package.

There is increasing convergence between telehealth and telecare with the introduction and expansion of remote monitoring as part of the 'telehealthcare' package available in a person's home. Encompassing physiological monitoring, safety and security, information and support services and home based medical applications, telehealthcare solutions maximise independent living and minimise the risk to people remaining at home (including people with dementia). They help to alleviate inequalities of service provision due to geography. This is particularly important for access to very specialist advice (eg for neurological services) and for delivery of rehabilitation in a model that maximises skill mix and remote mentoring.

Telehealth and telecare add much to the care and support of people with long term conditions and their carers and should become 'standard' components of our care pathways. Telehealthcare can improve the experience of care by reducing the need for travel to receive care and treatment. It supports self management, promotes confidence, reduces anxiety and decreases social isolation. It can facilitate better prevention, anticipatory care and earlier intervention and allows people the opportunity to receive care safely and effectively at or closer to home. Community hospitals need to be supported by technology that improves connectivity and diagnostics. This supports networks of learning for clinicians and connects GPs and specialists remotely to share knowledge, skills and avoid unnecessary referrals.

Telehealthcare is applied in a variety of ways in pathways for dermatological, cardiac, respiratory and neurological conditions. A first step in designing a telehealthcare service for a specific care group is to segment the population. For example a tiered approach to telehealthcare for people with COPD may be:

1. Web-based support for self management - widely available to all in the most appropriate media for the learning needs

2. Digital prompts for people with mild to moderate COPD and little additional limiting illness. Advice and prompts may be delivered by centralised call handling

3. Home-based physiological monitoring - targeted at people with moderate to severe/unstable disease and delivered with close supervision of the clinical team

4. Care management +/- telecare for people with complex/palliative care needs



Telehealth solutions can be email based such as the photo triage services for dermatology in Lanarkshire or Forth Valley. This has reduced costs and waiting times, speeded up skin cancer diagnoses and enabled 93% of patients to have definitive treatment at their first visit to hospital.

The specialist service from Quarriers, the National Tertiary Centre for Epilepsy for people with Learning Disability is a highly innovative service. Without access to the new video conferencing clinics, people and their carers would have to travel some 330 miles. For most people, this is out of the question due to the severity of their epilepsy or physical disabilities.

Contact: Scottish Centre for Telehealth

The Scottish telestroke programme is a group of projects that aim to improve access to hyper acute stroke care by providing thrombolysis decision support and TIA assessment remotely, using video consultation and PACS imaging. Telestroke project groups will now be a vehicle to support telehealthcare proposals throughout the stroke pathway, building on the established IT, MCN and patient and public links.


An audio-visual video link-up with Ninewells supports clinical decision-making in the minor injuries site at Crieff so staff can safely see and treat more people closer to home, especially during out-of-hours periods.

Contact: Claire McCormack, NHS Tayside Communications, 01382 424138


In Lothian people with COPD are being supported through technology in their homes with information about changes in symptoms being fed back to healthcare professionals, supporting and prompting self management and enabling early intervention when necessary.


Self Management

The Met Office Healthy Outlook ® service forecasts weather and viral conditions which are likely to increase COPD exacerbations. It is a telephone prompted self-management programme which empowers people to take preventative action. Moray CHCP developed a centralised model to extend the reach of this project in partnership with their community based telecare project.

Contact: Lorna Bernard, Moray Telehealthcare Project Manager


Tele-pulmonary rehabilitation is being delivered in Perth & Kinross where patients and a physiotherapy assistant in Pitlochry community hospital are linked using videoconferencing to a physiotherapist in Perth Royal Infirmary. In NHS Highland a research project is studying the delivery of pulmonary rehabilitation to patient's homes. The successful Tayside model is a template for tele-pulmonary rehabilitation throughout Scotland and is being looked at as a model for other rehabilitation e.g. Cardiac.


More details are available on the SCT website

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