Trying to join up care (care coordination) for people living with three or more long term conditions What it looks like, initial feedback and how we can make it even better 21 March 2018
Purpose of session • Provide a recap on the work we’ve been doing to better join up care of people living with three or more long-term condition • Why this is important • What we are trying to do • What have we done so far • Hear the stories of people who have experience of the changes we have made • Discuss what we do next to better join up care • How do we build on what has worked well? • How do we improve what has worked less well?
What are we trying to deliver/achieve with this work? • Looking at you as a person, not a set of conditions • Understanding what is important in your life and what you need to achieve this • Understanding what you and people around you need to do to better manage your condition • Helping the different people and services that support you to work together in a better way • Reduce the number of times you have repeat the same information to different people • Supporting you to better manage your own health • What does the proposed health and wellbeing planning process look like and why is this important?
How you have helped us • Collecting patient stories and films working with Revealing Reality and Healthwatch to understand experience of services and what’s important to people • Workshop at Millwall in January 2017 to understand what is important to people to include in new approach to joining up care • Smaller workshops in the summer to test wording in letters and care plan letters • Workshop at Millwall in September 2017 as part of launch to new approach
What we’ve done – care coordination Health and social care professionals working together Person centred care Help find and access services you planning – a Specialist 1 Patient need different type of Discuss/assess Planning discharge conversation Allied GP arrangements goals and needs health professional Discuss complex cases/issues with Care those involved in coordinator Social care Identify who worker needs this care Access to specialist Pharmacist opinion when Mental needed Regular review and health update of care plan with patient/family Supporting people to better manage their own health and well-being Source 1: https://www.england.nhs.uk/london/wp-content/uploads/sites/8/2015/03/lndn-prim-care-doc.pdf Source 2: Adapted from Carter, Chalouhi, Richardson – What it takes to make integrated care work (McKinsey Health International, 2011)
Progress • The holistic needs assessment has been reviewed to make it more appropriate for people with long term conditions, as well as frail older people. It is now more person centred. • It incorporates health and wellbeing questions and a new person centred care plan and crisis plan that has been developed through a care planning working group and patient focus groups. • Since October 2017 all practices across Southwark have begun to work in this way • So far nearly 800 patients across the borough have received this new approach
Any questions?
About Healthwatch Launched in 2013 A Healthwatch in every local authority We work with our local population We are independent organisations We are a 'critical friend’ Commissioned to engage Conduct interviews with people going through Care Coordination Deliver a group session Produce a report with recommendations
What we did… Patient Signed Arranged Talked Typed Today’s Letter, people a time to with up what event to flyer and up to visit at people people find out topic take part the and their had said what guide person’s carers / people home family think
Information provided How were interviewees invited to appointments? 7 were invited to take part by telephone. Some of them said this was positive but another felt a • letter would have been better as he is hard of hearing. • 3 were invited by letter, and 1 of them then had a call to confirm the appointments, which “The phone call from the clarified things. Another family said they would have liked a confirmation phone call. surgery Was the information clear and understandable? clarified what the • 2 said they understood the information given, 4 did not, and 4 were unsure. Misconceptions appointment included thinking it was about just one health condition, or a health check. 2 people did not was for, so I understand the term ‘holistic.’ understood Some people see the professional involved quite often so may not have expected anything what was • going to unusual. happen and Were interviewees able to prepare? why.” 7 people were not told to prepare, or did not feel they had the information needed to prepare. • 1 person felt well-prepared due to being a PPG member. 1 received a questionnaires which helped her prepare, though she did not understand all the questions.
The appointments • 6 people have had two separate appointments (though in one case interrupted by a medical emergency). 2 have had a combined appointment, and 1 a series of discussions. 1 person is waiting for their second appointment. • A few people have had a follow-up appointment booked, but for many it has not yet been six weeks.
Appointments: where, how many, how long, who? Where: Some patients had their appointment at the surgery and some at home (some of these being • housebound). One person who was visited at home noted this as a positive as he felt comfortable there. • Who: Professionals who led first appointments included nurses or health visitors. Professionals who led second appointments included GPs or a practice pharmacist. Combined appointments might have been with a nurse. Not everyone knew the job titles of people they had seen. • How long: The length of first appointments ranged from 20-60 minutes and second from 10-60 minutes. Combined appointments were 1-2.5 hours long. One patient described 45 minutes as ‘enough’, another said 20 -25 was too short and he did not know how • best to utilise it. • The 2.5 hour appointment was difficult as the patient’s husband was waiting outside.
What types of things were discussed? • Most people who had had two separate appointments said that the first appointment was mainly a physical check-up (e.g. blood pressure, blood “During both tests, memory tests, ears). appointments, I was Among the 8 people who have completed both appointments or a combined • able to talk about appointment: the things I wanted • 4 described a detailed general conversation covering many things that to and to ask are important to them. questions. The lady 1 had covered some things important to them but not others; 1 • at the second mentioned ‘future goals’ but felt they did not have many. appointment was But 1 person said they had covering only their physical health and • good at listening .” medications ‘not other needs’, and 1 family were unhappy that only one of several conditions had been discussed.
Manner of staff • Everyone said they understood what staff were saying, even if they didn’t understand the process. “What a wonderful Several patients knew the person they were seen by, and one said that this made it • person! I felt so easier to open up to them. free to speak with Everyone who commented on the manner of staff (9) was positive: adjectives • her. I was able to include ‘polite’, ‘friendly’, ‘soothing’, ‘great’, ‘kind’, ‘lovely.’ open up to her and tell her everything. • 5 patients specifically commented conversations felt comfortable, natural or She drew all of this relaxed, and they had been able to open up and talk openly. No-one reported out of me with her finding it strange or unpleasant to talk about their wider wellbeing. soothing Some commented on staff being good listeners, and one person highlighted it as a • demeanour… I am a particular positive that the professional ‘doesn’t forget anything and writes private person.” everything down.’ 2 people felt a bit rushed due to the professional making it known they had • another appointment to get to.
Care Plan • Do you have a copy? 6 people have had a copy of their Care Plan. For 2 more the process is incomplete. 2 have not had a copy, but 1 of these is told the professional is writing it up. • What does it cover? 2 people commented that their plan was comprehensive and covered the topics discussed. 1, however, felt it was not holistic as they had misunderstood the process to be about just one condition. Another patient’s plan is focused on weaning off medications, but this reflects her priorities. • Thoughts on format Comments about the format included that it was set out clearly but a bit small, or clear and easy to read. One person’s plan included acronyms he didn’t understand.
Recommend
More recommend
