ABSTRACT
So far national and international policies guiding the care and management of people with long-term conditions (LTCs) have been reviewed, along with the key principles relating to care provision, including case management and the importance of self-care. The physical and psychological aspects of living with an LTC have been discussed along with social influences on health. The key principles of behaviour change and motivational interviewing have been introduced and examples provided of how to put these principles into practice. In Chapter 6 signs, symptoms and criteria relating to diagnosis were introduced to ensure that people with LTCs are identified. The importance of IT systems, the use of shared records and the benefits of assistive technology should also not be forgotten. So what next? you may ask. Once diagnosis is established and the
This chapter provides a practical guide on clinical management including issues such as: writing a protocol, registration, recall and review, followup appointments, referral criteria and clinical audit mechanisms. Ways of identifying patients in the practice population to ensure registers are up to date are discussed, including how to ensure an effective call/recall system.
