Long Term Conditions Collaborative: Improving Care Pathways

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


Improvement Actions:

  • Develop intermediate care
  • Build effective working relationships with colleagues in other agencies
  • Lead and support a shift in culture for health professionals from paternalistic to one that empowers and enables
  • Review and develop roles and enhance skill mix


Rehabilitation/enablement is a continuum of enabling interventions. These may include early anticipatory interventions, or targeted preventative work such as falls and fracture prevention. It also includes assessment, diagnosis and enablement through specific treatment (eg building effort tolerance) as well as support for self management and symptom management of long term conditions. It always involves maintenance or recovery of function including social participation and work.

Why does rehabilitation matter?

  • It promotes safety and independence at home for high risk, vulnerable people including those with dementia - preventing avoidable admissions to hospital and to long term institutional care
  • It delivers safe, supported and timely discharge from hospital - especially for people with complex needs - reducing hospital length of stay
  • It makes effective use of 'first point of contact practitioners' and offers alternative pathways that reduce waiting times
  • It reduces dependency on health and social care support and associated costs
  • It delivers significant cost savings through alternative pathways of care and reduced longer term support costs

The Delivery Framework for Adult Rehabilitation aims to make rehabilitation services more accessible, delivered closer to home and an integral part of a care pathway. Rehabilitation Co-ordinators are working across health and social care services to support improvements in the patient journey through mapping and service redesign.

Rehabilitation is a key component of all pathways for long term conditions. It has an established role in pathways for people with cardiac disease and heart failure, chronic lung disease and chronic neurological conditions.

Three focused and measurable areas of work have been identified as new national priorities for rehabilitation services:

  • Musculoskeletal Rehabilitation
  • Rehabilitation/Enablement Services for Older People
  • Vocational Rehabilitation

These focused areas will deliver radical re-design of rehabilitation services providing safe, cost effective and sustainable care for patients.


National Musculoskeletal ( MSK) Programme

This programme has a tiered approach. Key components are:

  • Self management support via web-based access to new innovative services throughout NHSScotland, eg the Working Backs Scotland site and home based back pain rehabilitation are to be made available over the internet.
  • Self referral through a centralised referral management system to expert physiotherapy advice to reduce GP consultation rates and speed up referral for orthopaedic surgery - work in Lothian is being evaluated.
  • Integrated multi-disciplinary teams working within community settings carry protocol led triage with onward referral to the most appropriate service.

Chronic Pain

The MSK programme will be a key component of the tiered model for the management of chronic pain in Scotland. The pathway for chronic pain addresses themes, gaps and priorities identified in the 2007 report Getting Relevant Information on Pain ( GRIPS). For more information contact pete.mackenzie@scotland.gsi.gov.uk or visit www.nhshealthquality.org/nhsqis/7350html

A service model for chronic pain has been developed by the Chronic Pain Steering Group. Please see Appendix 3.

Vocational Rehabilitation/Fit for Work Services

These services aim to reduce longer term sickness absence and assist individuals within the workplace through rapid access to support and specialist advice from a dedicated vocational rehabilitation team. A 'fit for work' service, funded through Department of Work and Pensions and the Scottish Government, adopts a case management approach, focusing mainly on small and medium-sized businesses that lack their own occupational health service, and on workers in low-paid employment.

Pulmonary Rehabilitation

Pulmonary rehabilitation, delivered by a multidisciplinary team and including support for self management, can improve the health-related quality of life, exercise capacity and breathlessness of people with COPD. Recent innovations include delivery outwith hospital and through telehealth support. There is good evidence to support the benefits exacerbation and it is an essential criterion within QIS Standards for COPD.

Cardiac Rehabilitation

Comprehensive cardiac rehabilitation is exercise training together with education and psychological support that encourages people to make lifestyle changes to prevent further cardiac events. It is inexpensive, saves lives, helps people return to normal living and is being adapted for people with heart failure. The Braveheart project in Falkirk connects older people who have participated in cardiac rehabilitation with new entrants to the programme. This has produced considerable benefits for participants, mentors and health professionals alike.

Neuro rehabilitation

QIS Clinical Standards for Neurological Health Services includes a criterion around rehabilitation services. The Neurological MCN in Forth Valley has embedded rehabilitation within their pathway for neurological conditions.

Contact Derek Blues, Palliative Care and Neurological Disease MCN Manager: derek.blues@nhs.net

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