coordination) for people living with three or more long term - - PowerPoint PPT Presentation

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

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)

What we’ve done – care coordination

Health and social care professionals working together

Social worker Allied health professional Mental health Patient Pharmacist Care coordinator Specialist1 GP Help find and access services you need Planning discharge arrangements Access to specialist

• pinion when

needed

Regular review and update of care plan with patient/family

Discuss complex cases/issues with those involved in care

Discuss/assess goals and needs Supporting people to better manage their own health and well-being Person centred care planning – a different type

• f

conversation

 

Identify who needs this care

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 Letter, flyer and topic guide Signed people up to take part Arranged a time to visit at the person’s home Talked with people and their carers / family Typed up what people had said Today’s event to find out what people 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

clarified things. Another family said they would have liked a confirmation phone call.

Was the information clear and understandable?

• 2 said they understood the information given, 4 did not, and 4 were unsure. Misconceptions

included thinking it was about just one health condition, or a health check. 2 people did not understand the term ‘holistic.’

• Some people see the professional involved quite often so may not have expected anything

unusual.

Were interviewees able to prepare?

• 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 phone call from the surgery clarified what the appointment was for, so I understood what was going to happen and why.”

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 tests, memory tests, ears).

• Among the 8 people who have completed both appointments or a combined

appointment:

• 4 described a detailed general conversation covering many things that

are important to them.

• 1 had covered some things important to them but not others; 1

mentioned ‘future goals’ but felt they did not have many.

• But 1 person said they had covering only their physical health and

medications ‘not other needs’, and 1 family were unhappy that only

• ne of several conditions had been discussed.

“During both appointments, I was able to talk about the things I wanted to and to ask

• questions. The lady

at the second appointment was good at listening.”

Manner of staff

• Everyone said they understood what staff were saying, even if they didn’t

understand the process.

• Several patients knew the person they were seen by, and one said that this made it

easier to open up to them.

• Everyone who commented on the manner of staff (9) was positive: adjectives

include ‘polite’, ‘friendly’, ‘soothing’, ‘great’, ‘kind’, ‘lovely.’

• 5 patients specifically commented conversations felt comfortable, natural or

relaxed, and they had been able to open up and talk openly. No-one reported finding it strange or unpleasant to talk about their wider wellbeing.

• Some commented on staff being good listeners, and one person highlighted it as a

particular positive that the professional ‘doesn’t forget anything and writes everything down.’

• 2 people felt a bit rushed due to the professional making it known they had

another appointment to get to.

“What a wonderful person! I felt so free to speak with

• her. I was able to
• pen up to her and

tell her everything. She drew all of this

• ut of me with her

soothing demeanour… I am a private person.”

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.

How useful is the Care Plan?

3 people had not looked at their Care Plan until our interview. A few felt they had not been told what to do with it. The 6 people who had been given their plans had different feelings about how useful it would be:

“If a nurse comes, I will give her the plan, but won’t she want to hear from us directly about Mum? Every day is a different day… this is a stereotype, very regimental.” “I don’t fully understand how it will be utilised in the future. I didn’t expect the Care Plan to be as it was.” “It’s a good plan, I like it. I feel more in control of my medications now.” “It could help me to explain issues quickly – it’s good to have everything in one place.” “I don’t think she told me what to do with the printout...It would be a good idea to take it to appointments, but I wasn’t told to do that.” “[I could take it to appointments] to help them know what is happening to my health.”

Table discussions

Communication and preparation

• What is the best way to invite people to Care Coordination appointments?
• How can we explain Care Coordination better to people?
• How can we help people prepare to talk with the doctor or nurse about the things that are important to them?

The appointments

This is supposed to be a different type of conversation that is centred around what is important to the patient

• What would help people feel confident and able to talk about topics that are important to them and discuss and agree

goals?

• What is currently stopping this?
• How can we help patients feel that the appointment is an equal discussion between them and the professional?
• What are your thoughts on
• who the discussions are with e.g. GP, nurse
• Where they are e.g. home or practice
• How long they are?

Care Plan and after the appointment

• Is it useful and in what way? How would or could you use it?
• How could we make this more useful? E.g. content, layout etc
• What would make you share it with the people involved in your care?

How we communicate with you about the work we are doing

We want to use this on our website and in documents when we talk about working together to improve care in

• Southwark. What do you think?

What next…

• We will write up discussions from today
• Healthwatch will write a report with complete findings and

recommendations, based on what you have said today

• Healthwatch will give the report to the Local Care Networks
• The Local Care Networks will use the report to further improve care

coordination for people living with multiple long term conditions