Optimising Care Transitions for Multiple Long-Term Conditions

This technical report presents findings from a stakeholder engagement workshop conducted in collaboration with the Digital Health & Care Innovation Centre (DHI). The workshop aimed to explore the complexities of health and social care transitions for individuals with multiple long-term conditions (MLTC). Participants included health and care service providers, university representatives, and policymakers. The report identifies the challenges faced by people with MLTC, particularly regarding care transitions, which are often marked by fragmentation and lack of coordination. It discusses the importance of integrating systems engineering and systems thinking approaches to enhance care delivery. Key characteristics of good care, as defined by workshop participants, include person-centeredness, coordination, and accessibility. The report also highlights the need for holistic assessments and the establishment of continuous care relationships to improve outcomes for individuals navigating complex health systems. Additionally, it addresses barriers to effective care delivery and suggests potential improvements to the care journey for individuals with MLTC.