S80 - Day 2 - 1045 - Building the house of care
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Transcript of S80 - Day 2 - 1045 - Building the house of care
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Building the House of Care
January 2014
Martin McShaneJacquie WhiteEd Mitchell
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Overview
• Context
• Principles
• Resources
• Discussion
2
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• Context
• Principles
• Resources
• Discussion
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Patie
nts (
%)
Age band (Years)
Morbidity (number of ETGs) by age band
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7+
Number ofconditions
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BMJ 2009;339:b2803 4
A man being treated for heart failure in UK primary care rejected the offer to attend a specialist heart failure clinic to optimise management of his condition. He stated that in the previous two years he had made 54 visits to specialist clinics for consultant appointments, diagnostic tests, and treatment. The equivalent of one full day every two weeks was devoted to this work.
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Changing the nature of the conversation….the biggest challenge?
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The soft stuff…is the hard stuff
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Mindsets and beliefs
Values
Individual behaviours
SOURCE: Scott Keller and Colin Price, ‘Performance and Health: An evidence-based approach to transformingyour organisation’, 2010.
Needs (met or unmet)
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Year of Care Costs
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Relationship between number of long-term conditions and cost
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LTC Year of Care Programme
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Gearing of investment across the system
Public HealthSocial Care(H&WB Board)
Primary Care£200
Comm/MH£500
Specialised£300
Acute£1000
£2000/head of population
NHS England CCGs
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NHS Expo Seminar Domain 2
Gearing in activity into acute care
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GP Specialist
1990
Specialist
2014
CARE GAP
Activity
Complexity
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Qu
alit
y o
f li
fe
£1 £10 £100 £1,000
ICU
ACUTE CARE
0%
COMMUNITY CARE
Self-management
Long Term Condition Management incl Cancer
Third sector provision
Primary Care
100%
Consultant-led services
Specialist teamsSpecialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
£5,000
Cost of Care per Day
Risk profiling
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COMPLEX CARE PRACTICE
???
Bridging the gap
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LTC Year of Care Programme
Impact of coordinated care
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Person centred coordinated care“My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes”
Communication
Information
Decision-makingCare planning
Transitions
My goals/outcomes
Emergencies
14
What people with LTCs want
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1. Engaged, informed, empowered individuals and carers
2. Organisational and clinical processes
3. Health and care professionals working in partnership
4. Commissioning 15
Person Centred Coordinated Care
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Engaged, informed
individuals & carers
Commissioning
Organisational & clinical processes
Person-centred,
coordinated care
Health & care professionals committed to partnership
working
Plan
Study
Do
Act
The House of Care
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–Informational continuity–Management continuity–Relational continuity
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The House supports:
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The House of Care in value to people/patients:
The House supports National Voices ‘I’ statements
My goals/outcomes e.g.• All my needs as a person were
assessed and taken into account.
Communication e.g.• I always knew who was the
main person in charge of my care.
Information e.g.• I could see my health and
care records at any time to check what was going on
Decision-making e.g.• I was as involved in
discussions and decisions about my care and treatment as I wanted to be. Care planning e.g.
• I had regular reviews of my care and treatment, and of my care plan.
Transitions e.g.• When I went to a new
service, they knew who I was, and about my own views, preferences and circumstances.
Emergencies e.g.• I had systems in place so
that I could get help at an early stage to avoid a crisis.
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The House of Care in value to NHS:£1.2bn:Avoid ambulatory care sensitive admissions though e.g. following NICE guidelines (1)
£0.8bn:Reduction of hospital admissions for common LTCs through integrated care esp frailty, comorbid (2)
£0.8-1.2bn:Reduce use of low value drugs, devices and elective procedures using commissioning analytics and clinician education (3)
£0.2-0.4bn:Empower people in supportive self-management (4)
£1-1.6bn:Shift activity to cost effective settings e.g. pharmacy minor ailments (5)
c.£5.5bn:Incentivised wellness programmes in healthy pop & early stage LTCs inc. smoking cessation, salt ↓, exercise ↑(6)
£0.4-0.6bn:Avoidance of drug errors e.g. through electronic records/e-prescribing (7)
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20
Community Care Primary Care
GenHospitalseral
University/ Specialist Facilities
Social Care
GeneralHospital
ICare
The Future: 2014-2019
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The House of Care - Person centred, coordinated care at three levels:
National:What can national organisations and policy makers can do to enable construction of the House of Care at the next two levels.
Local:How local health economies ensure that the House of Care involves a whole system approach, including ‘more than medicine’ offers
Personal:How the House of Care gives professionals on the front line a framework for what they need to do for patients and ask local commissioners to secure for them
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CCGs: Building the House at the local, community level
What
• What are the principles and philosophy behind the care which commissioners wish to provide e.g. National Voices 'I' statements
• What is the model to use as framework or providing this care (e.g. the House of Care supporting care planning)
Which
• Which population of people with LTCs are being addressed (risk stratification approaches, GP disease register, frailty index etc)
Where, when, whom
• Decide the local model of care i.e. where and when will all the components of the house be delivered for each group of people, and by whom
How
• Write the specification of how to achieve this including the financial model that will support what needs to be done (tariffs, contracts, incentives etc that match the model of care)
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Building the House – The House of Care Toolkit
• A framework to bring together all the relevant national guidance, published evidence, local case studies and information for patients and their carers.
• It includes information on what tools and resources are required to achieve person-centred coordinated care and how these can be effectively commissioned.
• Resources are arranged into the four key components of the House with summaries of the impact that could be achieved, based on current evidence and details about where to find additional information.
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To Enter the House first chose your level:
NationalPersonal Local
Examples of local examples of good practice
that will inform the commissioning of services
at a local level .
Supporting for professionals, services
users and carers to work together to understand, plan and deliver person
centred coordinated care.
National and international guidance, evidence, tools
and resources that will enable the construction of the House of Care at the
next two levels.
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Organisational and Clinical Processes
Person centred- coordinated care
Health and Care Professionals committed to partnership
working
• Integration• Culture • Technology• Care Co-ordination• Care Planning
• Information and Technology• Care Planning• Safety and Experience
Informed and engaged patients
and carers
• Self Management• Information and
Technology• Group and Peer
Support• Care Planning• Carers
Commissioning • Service User and Public Involvement• Contracting and Procurement
• Needs Assessment and Planning• Joint commissioning • Metrics
• Evaluation• Care Planning
Build my own house
Click on the links below for more information about
each component and use this to build your own house
• Guidelines, Evidence and National Audits
• Workforce and Organisational Structures
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Enables individuals to make informed decisions which are right for them, and empower them to self-care for their long term conditions in partnership with health and care professionals. It relies on four key components, all of which must be present for the goal, person-centred coordinated care, to be realised
– Commissioning – which is not simply procurement but a system improvement process, the outcomes of each cycle informing the next one.
– Engaged, informed individuals and carers – enabling individuals to self-manage and know how to access the services they need when and where they need them.
– Organisational and clinical processes – structured around the needs of patients and carers using the best evidence available, co-designed with service users where possible.
– Health and care professionals working in partnership – listening, supporting, and collaborating for continuity of care. 26
Person centred- coordinated care
Back to house
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Care Planning Professionals working in partnership with people living with long term conditions and their carers, identifying priorities, discussing care and support options, agreeing goals they can achieve themselves, and co-producing a single care plan, that meetstheir physical, social and emotional wellbeing needs regardless of how manylong-term conditions they have.
Consultation preparation
Research by the Health Foundation has identified elements that can make a
consultation between patient and healthcare
professional more successful.
Key Components• Focussing on
receptionist's conversations in general practice
• Practice Health Champions
• Appointment guides.
Back to house
Care planning process
An ongoing process encouraging an interactive
partnership between clinician and patient to
support self management of patients and their long term
condition.Key Components
• Information provided to the patient prior to the appointment
• During the appointment achievable goals should are set in partnership. I
• Capturing gaps between preferences and care received
• Feeding back preferences to inform future planning.
Medicines optimisation
To ensure the best possible outcomes from medicines for people living with long
term conditions.
Key Components • Ongoing, open dialogue
with the patient and/or their carer about their choice and experience of using medicines to manage their condition
• Recognising the patient’s experience may change over time even if the medicines do not.
Engaged, informed
individuals and carers
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Engaged, informed
individuals and carers
Consultation Preparation
Resources
Right Conversation at the Right Time, The Health Foundation http://www.rightconversation.org/
When doctors and patients talk: making sense of the consultation, The Health Foundation http://www.rightconversation.org/whendoctorsandpatientstalk.pdf
Back to care planning
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Engaged, informed
individuals and carers
Care Planning Process
Resources
Shared decision making, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/
Tools for shared decision making, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/tools-sdm/
Care Planning, Royal College of General Practitioners http://www.rcgp.org.uk/clinical-and-research/clinical-resources/care-planning.aspx
Deciding together Care planning in long term conditions, NHS Kidney Care , February 2013http://www.cmkcn.nhs.uk/attachments/article/37/Deciding%20together%20%20Care%20planning%20in%20long%20term%20conditions[1].pdf
Back to care planning
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Engaged, informed
individuals and carers
Medicines Optimisation
Resources
Medicines Optimisation: Helping patients to make the most of medicinesGood practice guidance for healthcare professionals in England, Royal Pharmaceutical Society. http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf
Good practice in prescribing and managing medicines and devices, General Medical Councilhttp://www.gmc-uk.org/Prescribing_Guidance__2013__50955425.pdf
Back to care planning
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Integration Ensuring care is designed and delivered around the needs of the individual.Integration is particularly important for people with complex care needs.Services should be joined-up to promote improved outcomes for individuals in need of health and social support, enabling them to live not just longer, but better lives.
Care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes
Back to house
Interdisciplinary working
Professionals from different organisations across health and social care and the voluntary sector working closely together ensuring that care feels coordinated to people living with long term conditions and their carers.
Key Components • Single point of contact• Professionals talk to each other• Services quick and responsive
people are promoted to stay independent and active
• Care developed around the individual and not the system
Care Transition
Ensuring a seamless transition for people with long term conditions between different care settings.
Key Components • Transition following discharge from
hospital • Transition related to changes in long
term care needs • Transition from children's to adult
services.
Health & care professionals committed to partnership
working
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Interdisciplinary Working
Resources
Integrated care for patients and populations: Improving outcomes by working together - A report to the Department of Health and the NHS Future Forum, The Kings Fundhttp://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together
Integrated Care and Support Pioneers programme, NHS IQhttp://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions/integrated-care.aspx
Integrated Care – Better Care Fund – Local Government Associationhttp://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE
Integrated care value case toolkithttp://www.local.gov.uk/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4060433/ARTICLE
ICASE - Integrated Care Support and Exchange http://www.icase.org.uk/pg/dashboard
Kings Fund Integrated care: making it happenhttp://www.kingsfund.org.uk/projects/integrated-care-making-it-happen
Back to integration
Health & care professionals committed to partnership
working
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Care Transition
Resources
Lost in transition, Moving young people between child and adult health services, Royal College of Nursinghttp://www.rcn.org.uk/__data/assets/pdf_file/0010/157879/003227_WEB.pdf
Transitions between children’s and adult’s health services, and the role of voluntary and community children’s sector, VSS POLICY BREIFINGhttp://www.ncb.org.uk/media/42225/transition_to_adult_services_vss_briefing.pdf
Transition, National Council for Palliative Carehttp://www.ncpc.org.uk/transitions
Coordinated transition between health and social care, NICEhttp://www.nice.org.uk/media/7C5/66/TranstionBetweenHealthAndSocialCareDraftScope.pdf
Back to integration
Health & care professionals committed to partnership
working
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The House of Care – Build your own houseWhat elements need to be in place for YOUR local population?
Commissioning
Organisational and clinical processes
Engaged, informed individuals & carers
Health & care professionals committed to partnership working
Back to house