This paper describes a co-ordinated service delivery model – the ‘house of care’ – that aims to deliver proactive, holistic and patient-centred care for people with long-term conditions.
It incorporates learning from a number of sites in England that are working to achieve these goals, and makes recommendations on how key stakeholders can work together to improve care for people with long-term conditions.
The house of care metaphor illustrates the whole-system approach needed to improve care, and emphasises the interdependency of each part. Care planning is at the centre; the left wall represents the engaged and informed patient; the right wall represents health professionals committed to partnership working; the roof represents organisational systems and processes; and the foundations represent the local commissioning plan. Key elements are as follows.
- People with long-term conditions play an active part in determining their own care and support needs through personalised care planning.
- Collaborative relationships between patients and professionals, shared decision-making and self-management support are at the heart of service delivery.
- Tackling health inequalities is a central aim, given that people in lower socioeconomic groups are more likely to experience long-term conditions.
- Each individual is engaged in a single, holistic care planning process with a single care plan regardless of how many different long-term conditions they have.
- Individual needs and choices are aggregated to provide a local commissioning plan.
- Self-management support may be provided by community and self-help groups alongside statutory services.