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GPs and others are helping patients manage their health and avoid hospital visits
Keeping people with long-term conditions out of hospital is going to be key for the NHS as the number of patients rises.
'Understanding what the patients want to achieve is important. This may be as simple as being able to make a cup of tea'
Identifying people at risk of deterioration and repeated hospital admissions and improving their health and self-management skills could achieve that aim. A scheme in Kent is offering such patients 12 weeks of intervention by health and other services in the hope that a holistic approach will make a lasting difference.
Early evidence suggests this can lead to fewer hospital admissions, shorter stays in hospital, an improvement in mental health and significant savings for the health service.Tailored care
The patients ? who have two or more long-term conditions and have been admitted to hospital twice within a year ? have their needs examined by a multidisciplinary group, with input from their GP, community and mental health staff, social care and health trainers. They may also be signposted to help with the patient's housing.
Typically the group usually first meets at the GP's surgery and then some may visit the patient at home to get a greater understanding of their circumstances and how this relates to their health. A programme of interventions and support is then drawn up.
This will be tailored to the patient and can include telehealth, changing medication, physiotherapy or occupational health support, and health trainer input. If their housing is having an impact on their health, the group will try to initiate changes to this.
Patients were also being put in contact with groups such as Age UK or weight management classes that could be of help to them.Taking responsibility
But it is not all one way. Patients are encouraged to take responsibility for their own health, by agreeing to lose weight, for example. Health trainer...