Long-term conditions

Long-term conditions (LTCs) can be defined as any ongoing, long-term or recurring conditions that can have a significant impact on people’s lives.

Many people suffer from several LTCs. Related terms for LTCs are ‘non-communicable diseases’1 and ‘chronic conditions’. LTCs include conditions such as diabetes, cancers, cardiovascular diseases, respiratory diseases, mental illness, chronic pain, chronic kidney disease and dementia.

As the population ages and lifestyles change, the health system needs to respond to increasing numbers of people with LTC. This will require changes in healthcare provision. Primary care and community health have key roles in the prevention, detection and management of LTC.

New Zealanders living with LTC can expect:

  • high quality, patient focussed care (value and high performance)
  • care that is integrated across the health system (one team)
  • to be regarded as leading partners in their care (people powered).

A systematic approach to LTC management includes:

  • patient centred, proactive coordinated care for individuals with LTC health needs
  • systems capable of managing the growing health needs of the population and supporting wellbeing
  • equity of outcome for all populations.

LTC work programme

The Ministry Long-Term Conditions Programme provides support to the Ministry, Health Sector and NGOs by:

1. Providing leadership

Enables knowledge sharing for LTC management across all DHBs:

  • workshops showcasing LTC best practice
  • clinical director role for Long-Term Conditions team.

Facilitates guidance development supporting best practice across DHBs:

  • patient co design establishment and use of patient panel
  • chronic kidney disease management, diabetes quality standards and toolkit.

Enables sharing across LTC work programmes in Ministry.

2. Evaluating progress

  • Sets expectations for LTC management within DHB annual plans:
    • feedback on drafts.
  • Reviews quarterly LTC management progress across DHB annual plans:
    • developing relationships with DHBs around LTC.
  • Evaluates new initiatives aimed at LTC management improvement such as the Diabetes mental health project

3. Supporting Innovation and service improvement

  • Supports development of information and resources, where necessary, to fill gaps in LTC management:
    • self management guidance development
  • Supports testing and service development knowledge sharing for implementing new LTC models of care and clinical pathways:
    • Self-management support in primary care project

4. Providing tailored support where required

  • Change management support:
    • development of Diabetes Care Improvement Plans.

5. Programme measurement/assessment

  • Programme measurement and assessment can be reviewed and measured against:
    • the internationally recognised ‘characteristics of a high-performing chronic care system framework’ by Chris Ham
    • Ministry of Health LTC draft intervention logic framework. Copies available on request by emailing cvddiabetes@moh.govt.nz

1 A related term is non-communicable disease (NCD), or conditions that are not acquired by transmission between people. There is significant overlap between the two, for example, many NCDs are long term in nature, and LTCs and NCDs share many common lifestyle-related risk factors. There is not complete overlap however, for example some LTCs are communicable such as Hepatitis. The terms are sometimes used interchangeably. NCDs is more commonly used in international contexts such as by the World Health Organisation.

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