Long-term conditions: work programme

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. Read more about the Shifting care closer to home conference - Health Navigator website.
• 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
• health app quality assessment framework. Read more about the health applications assessment guidance.

Enables sharing across LTC work programmes in Ministry.

2. Evaluating progress

• Sets expectations for LTC management within DHB annual plans and reviews quarterly LTC management progress across DHB annual plans:
  • developing relationships with DHBs around LTC.
• Evaluates new initiatives aimed at LTC management improvement.

3. Supporting innovation and service improvement

• Supports development of information and resources, where necessary, to fill gaps in LTC management:
  • self management guidance (publication).
• 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 outcomes framework