Scotland’s House of Care. Jungle The individual's perspective.
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Transcript of Scotland’s House of Care. Jungle The individual's perspective.
Scotland’s House of Care
Jungle
The individual's perspective
The individual's perspective
3 out of 8757 hours
or 0.03%
Lots going on -• Mental Health Strategy for Scotland • People Powered Health & Well Being• Personal outcomes• Talking points• Co-creating health• New models of primary care• NUKA• Links worker programme• Integration of Health and Social Care• Self Directed Support• Connecting people to local opportunities • Social prescribing• Improvement, Empowerment, Evidence, Compassion
Commitment 15:
• We will work with partners, including the Royal College of General Practitioners and Long Term Conditions Alliance Scotland, to increase local knowledge of social prescribing opportunities, including through new technologies which support resources such as the ALISS system which connects existing sources of support and makes local information easy to find. We will also raise awareness, through local health improvement networks, of the benefits of such approaches.
Commitment 28
• We will continue to work with NHS Boards and other partners to support a range of health improvement approaches for people with severe and enduring mental illness, …….
An analogy- Convergent Evolution
We look for helpful approaches to similar issues in similar environments, which leads to ‘creatures/solutions ’ with similar ‘body shapes/ features’.
Useful touchstones
King’s fund report
• Self-management support can be viewed in two ways: as a portfolio of techniques and tools to help patients choose healthy behaviours; and a fundamental transformation of the patient–caregiver relationship into a collaborative partnership (De Sliva 2011, p vii).
King’s fund report
• Self-management support can be viewed in two ways: as a portfolio of techniques and tools to help patients choose healthy behaviours; and a fundamental transformation of the patient–caregiver relationship into a collaborative partnership (De Sliva 2011, p vii).
Gaun Yersel (2008)
• “The partnership with the individual is central to the self management agenda”
• “I am the leading partner in the management of my own health”
People in the Driving Seat• The House of Care approach to a enabling and personalised care for
people with LTCs
• Graham Kramer• Tim Warren
•
Basics
• The House of Care has proved very memorable and ‘sticky’, providing a strong visual image for a check list, with four equally critical structural elements, keeping a bit in the middle warm, dry and safe.
• Many have made use of it, and adapted it in lots of ways.
• People build their own house in their own context.
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies Health Care Organization
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies Health Care Organization
• QOF• Decision support• Biomedical
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies Health Care Organization
ProductiveInteractions
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Health Care Organization
Community
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Health Care Organization
Community
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Collab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Organisational Processes &
Arrangements
Healt
h &
care
p
rofe
ssio
nals
com
mit
ted
to
part
ners
hip
work
ing
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
Collab
ora
tively
ori
en
tate
d
healt
hcare
p
rofe
ssio
nalEngaged,
Informed, Empowere
d Individuals & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’ Informal and formal sources of support and care
sustained by the responsive allocation of resources
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Health Care Organization
Community
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Organisational Processes &
Arrangements
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’ Informal and formal sources of support and
care sustained by the responsive allocation of
resources
Person Centred Care and Support Planning*Health Care Conversation – which includes mental, physical & social Health*Shared Decision Making *Personal outcomes*Talking Points*Co-creating health
Person Centred Care and Support Planning*Health Care Conversation – which includes mental, physical & social Health*Shared Decision Making *Personal outcomes*Talking Points*Co-creating health
Values?
The clinical consultation between a Health Care Professional and a Person with a long term condition, is a meeting of equals and experts
Agree!
Disagre
e!
The person with a long term condition is in charge of their own life and managing their condition(s)
Agree!
Disagre
e!
The person with a long term condition is more likely to act upon the decisions they make themselves, rather than those made for them by a professional
Agree!
Disagre
e!
It is my role to value the person’s psychological and social well-being just as much as their physical health
Agree!
Disagre
e!
The collaborative care planning consultation (how the care plan is agreed) is more important than the Care Plan itself
Agree!
Disagre
e!
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Organisational Processes &
Arrangements
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’ Informal and formal sources of support and
care sustained by the responsive allocation of
resources
Story
Ok – what do you need to support a good conversation?
36
37
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Personal Outcomes?
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
Structured education
which is peer and
professionally co-designed
SharedCorrespondenc
e
Pre-consultation
results
Emotional psychological
support
Patient access to records
Recognition of Assets
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
Clinical expertise
Educated in SM
Reflective practitioners
Consultation skills/Attitudes
Multidisciplinary team
Leadership from the start, right through
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
ALISSAsset
Mapping
Joining people with their local
assets
Individual information
aggregated to inform joint
strategic commissioning
‘MORE THAN MEDICINE’ Informal and formal sources of support and
care sustained by the responsive allocation of
resources
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
Named contact
ITRecall system
Contractual arrangements – making
time
Organisational Processes &
Arrangements
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Organisational Processes &
Arrangements
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’ Informal and formal sources of support and
care sustained by the responsive allocation of
resources
Improved Outcomes
Structured education
which is peer and
professionally co-designed
SharedCorrespondenc
e
Pre-consultation
results
Emotional psychological
support
Clinical expertise
Educated in SM
Reflective practitioners
Consultation skills/Attitudes
Multidisciplinary team
Named contact
IT
Access & communication
Recall system
Patient access to records
Leadership from the start, right through
Contractual arrangements – making
time
Collab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Organisational Processes &
Arrangements
Healt
h &
care
pro
fessio
nals
com
mit
ted
to p
art
ners
hip
w
ork
ing
ALISSAsset
Mapping
Recognition of Assets
Joining people with their local
assets
Individual information
aggregated to inform joint
strategic commissioning
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
Coll
ab
ora
tively
ori
en
tate
d h
ealt
hcare
p
rofe
ssio
nal
Engaged, Informed, Empowere
d Individual
s & Carers
Health & Care
professional team
committed to
partnership working
Care & Support Planning
Conversation
‘MORE THAN MEDICINE’ Informal and formal sources of support and
care sustained by the responsive allocation of
resources
Some comments….
• I helps me make sense of a really complex world…
• It plays nicely with the other children in the playground…
• There is nothing new here…..• It has given me an overview of how the
system should and could work….
HoC useful for …..
ALISSAsset
Mapping
Joining people with their local
assets
Individual information
aggregated to inform joint
strategic commissioning
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
‘MORE THAN MEDICINE’ Informal and formal sources of support and
care sustained by the responsive allocation of
resources
Cod on the Tyne: Mental health/multiple physical /social issues
Next Cook Your Fish
ALISSAsset
Mapping
Joining people with their local
assets
Individual information
aggregated to inform joint
strategic commissioning
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
‘MORE THAN MEDICINE’ Informal and formal sources of support and
care sustained by the responsive allocation of
resources
Technical ‘handshakes’
Directories or‘Asset Mappinggroups’
Hyper local &locally relevant assets’
ALISSAsset
Mapping
Joining people with their local
assets
Individual information
aggregated to inform joint
strategic commissioning
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
‘MORE THAN MEDICINE’ Informal and formal sources of support and
care sustained by the responsive allocation of
resources
Evidence
Tower Hamlets : People with HbA1c< 7.5
May-08
Aug-08
Nov-08
Feb-09
May-09
Aug-09
Nov-09
Feb-10
May-10
Aug-10
Nov-10
Feb-11
30
35
40
45
50
55
60
YOC Practices Non YOC pratices
%
March 2012 - 92% care planning
9 key care processes in diabetes
- best reported in England (Ave.
20%) Those with all BP, HbA1C and Cholesterol ‘controlled’
2009 = 24%2012 = 34%
‘The new pathway is not only more patient centred but more efficient in time for both patients and health care professionals.’ (Practice team member)
Productivity: Improving…….
Cost per patientpractice level
pre YOC: £21 post YOC: £21
COPD:• Admissions …………..reduced by 50%• A&E attendance …………..reduced by 68%
Kirklees: Improvement
programme : saved £225K
Tower Hamlets: Emergency admissions
reduced by 15%.. saved £700K
Latest
• Multiple Conditions action plan• Three ‘early adopter’ sites
– GGC– Lothian– Tayside
• Presentation to ‘Essence of General Practice’ – Alan McDevitt, Paul Gray, Miles Mack
• Future investment• BHF
Sue Roberts – Care planning
• Care and support planning is about enabling better conversations between people living with long term conditions (LTCs) and health care practitioners that are focussed on what matters to the individual so that support and services can be tailored for each person.
• It is a meeting between those with technical expertise and those with lived experience in which the person is supported to identify their priorities and goals for living their life and the actions that they and/ or the service can take to help them achieve these.
Sue Roberts – Care planning
• Because introducing care and support planning involves changes to attitudes (mindsets), skills and clinic infrastructure it is also a powerful lever for culture and systems change within teams and across the wider community.
• It also improves job satisfaction for health care professionals who describe it as a ‘better way to work’.
Care and support planning is about enabling better conversations……..
Care & Support Planning
Conversation
between people living with long term conditions (LTCs)……
and health care practitioners….. Care &
Support Planning
Conversation
between people living with long term conditions (LTCs)……
It is a meeting between those with technical expertise and those with lived experience
Care & Support Planning
Conversation
so that support and services can be tailored for each person.
Care & Support Planning
Conversation
+
that are focussed on what matters to the individual Care &
Support Planning
Conversation
so that support and services can be tailored for each person.
Care & Support Planning
Conversation
• Because introducing care and support planning involves changes to attitudes (mindsets), skills and clinic infrastructure.
Care & Support Planning
Conversation
Care & Support Planning
Conversation
• it is also a powerful lever for culture and systems change within teams and across the wider community.
‘Local’ House of Care
‘National’ supports for the House of Care
Competence in care planning
Provision of development support for Care Planning conversations
NHS Education Scotland professional bodies, patient groups to develop National support for programme for Care planning
e.g’s of level of things
‘Regional’ supports for the House of Care
Co
llab
ora
tively
o
rien
tate
d h
ealt
hcare
p
rofe
ssio
nal
Healt
h &
care
p
rofe
ssio
nals
com
mit
ted
to
part
ners
hip
work
ing
Russian
Community Resources and Assets (‘More than medicine’)
both uncommissioned and those sustained by responsive commissioning
Coll
ab
ora
tively
ori
en
tate
d
healt
hcare
pro
fessio
nal
Organisational Processes &
Arrangements
En
gag
ed
, In
form
ed
, E
mp
ow
ere
d
Ind
ivid
uals
& C
are
rs
Healt
h &
Care
p
rofe
ssio
nal te
am
co
mm
itte
d t
o
part
ners
hip
wo
rkin
g
Care & Support Planning
Conversation
73
The individual's perspective
The individual's perspective