Long Term Conditions Collaborative: Improving Care Pathways

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


Improvement Actions:

  • Provide as much care as possible in the community
  • Make home care flexible, responsive and enabling
  • Develop community hospital role
  • Develop intermediate care


Shifting the Balance of Care aims to achieve better outcomes for people by delivering care and support at home, or closer to home in community facilities. This may involve shifting the location of care, sharing responsibility by empowering a different member of the multi-professional team, or shifting the focus of care through an anticipatory approach that prevents or delays dependency and need for more intensive support.

Community hospitals and local care centres

Community hospitals are as diverse as the communities they serve. In the last decade, community hospitals have moved away from the traditional inpatient model towards being a hub for community health services. Community heath services are key to providing more care closer to home, ideally integrated or co-located with social care, housing support and third sector organisations.

Care at home with support for carers

Most people want to be cared for safely in their own home for as long as possible. Maximising care at home shifts the focus from institutional care to flexible and responsive care and support provided at home. To achieve this, paid and unpaid carers need greater education and support to manage care at home, including better access to respite care. They are important members of the extended community team, alongside partners from community and voluntary sector organisations.

Intermediate care

Intermediate care is a range of integrated community based services to prevent avoidable hospital admission, support timely discharge from hospital, maximise independent living and avoid premature long term care. Some services are condition specific (eg COPD hospital at home/stroke supported discharge) but most are generic services for frail older people delivered by integrated community teams with timely access to specialist expertise. Some services also support people in care homes, bridging the gap between home and hospital. For more information refer to the Joint Improvement team website:

Falls Prevention

The Prevention and Management of Falls Community of Practice has a number of active sub-groups and a wider, online Falls Community to share knowledge, information, good practice and resources to support the development of services to identify older people at greatest risk of falling and ensure timely access to comprehensive falls management programmes delivered at home or close to home. For more information refer to the Falls Community Website -


Releasing Time to Care

Productive Community Services ( PCS) is an organisation-wide change programme developed by the Institute for Innovation and Improvement. It systematically engages front-line nursing and therapy teams in improving quality and productivity. It is a practical application of Lean based techniques that empowers staff to challenge practice and use their experience and knowledge to develop local solutions to:

  • Create a stable and organised working environment
  • Predict and plan work
  • Promote effective team working
  • Remove waste and reduce frustration
  • Increase patient facing contact time
  • Deliver high quality, safe and consistent care for each patient
  • Connect more closely with the patient experience

Through Releasing Time to Care in Community Hospitals, teams in NHS Borders and Lanarkshire are improving access and flow to their community beds, increasing opportunities for rehabilitation by greater capacity from allied health professionals, taking a more streamlined approach at handovers and team meetings and releasing GP and nursing time to directly care for people. Through action learning sets and networking the learning is shared with teams from other clinical areas and Boards.

Augmented Care at Home Service

Invergordon County Community Hospital, Ross & Cromarty. This service is integrated with the practice and community hospital and facilitates early discharge and unnecessary admission to hospital. Recently, supporting joint working with Local Authorities and Health, the service aims to prevent Delayed Discharges for those patients waiting for home care provision.

Contact: Isobel Clayton, Team Leader
Tel. 01349 855670

East Ayrshire CHP - Partnership Working Step-up, Step-down Care

Ross Court in East Ayrshire is an example of partnership working between the CHP and East Ayrshire Council to develop a locally based service that will benefit older people in the community. It provides a flexible, needs led service within a homely environment where individuals can receive time limited support covering a range of complex needs which may be physical, emotional, social or recreational and which may include nursing and medical interventions. This provision is a step-up, step-down support and is used to reduce the likelihood of acute hospital admission, enabling the person to return home.

NHS Dumfries and Galloway - Short Term Augmented Response Services ( STARS)

STARS provides early input to patients in order to avoid unnecessary hospital admission and supports early discharge by providing intensive rehabilitation in the person's own home.


Evaluation of 'Closer to Home' Demonstration Sites

A report from the National Primary Care Research and Development Centre summarises the experiences of 30 demonstration sites:

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