scotland’s house of care. jungle the individual's perspective

Scotland’s House of Care

Jungle

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

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

• QOF• Decision support• Biomedical

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

ProductiveInteractions

Informed,ActivatedPatient

Prepared,ProactivePractice Team

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Health Care Organization

Community

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Community

Collab

tively

Organisational Processes &

Arrangements

INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE

sustained by the responsive allocation of resources

Collab

tively

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

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Community

Collab

tively

fessio

Arrangements

fessio

tively

Engaged, Informed, Empowere

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

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

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

The person with a long term condition is in charge of their own life and managing their condition(s)

Agree!

Disagre

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

It is my role to value the person’s psychological and social well-being just as much as their physical health

Agree!

Disagre

The collaborative care planning consultation (how the care plan is agreed) is more important than the Care Plan itself

Agree!

Disagre

Collab

tively

fessio

Arrangements

fessio

tively

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Conversation

resources

Ok – what do you need to support a good conversation?

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Personal Outcomes?

Collab

tively

fessio

tively

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Conversation

Collab

tively

fessio

tively

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Conversation

Structured education

which is peer and

professionally co-designed

SharedCorrespondenc

Pre-consultation

results

Emotional psychological

support

Patient access to records

Recognition of Assets

Collab

tively

fessio

tively

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Conversation

Clinical expertise

Educated in SM

Reflective practitioners

Consultation skills/Attitudes

Multidisciplinary team

Leadership from the start, right through

Collab

tively

fessio

tively

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Conversation

ALISSAsset

Mapping

Joining people with their local

assets

Individual information

aggregated to inform joint

strategic commissioning

resources

Collab

tively

fessio

tively

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Conversation

Named contact

ITRecall system

Contractual arrangements – making

Arrangements

Collab

tively

fessio

Arrangements

fessio

tively

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Conversation

resources

Improved Outcomes

Structured education

which is peer and

professionally co-designed

SharedCorrespondenc

Pre-consultation

results

Emotional psychological

support

Clinical expertise

Educated in SM

Reflective practitioners

Consultation skills/Attitudes

Multidisciplinary team

Named contact

Access & communication

Recall system

Patient access to records

Leadership from the start, right through

Contractual arrangements – making

Collab

tively

fessio

Arrangements

fessio

ALISSAsset

Mapping

Recognition of Assets

assets

tively

d Individual

s & Carers

Health & Care

professional team

committed to

partnership working

Conversation

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

assets

resources

Cod on the Tyne: Mental health/multiple physical /social issues

Next Cook Your Fish

ALISSAsset

Mapping

assets

resources

Technical ‘handshakes’

Directories or‘Asset Mappinggroups’

Hyper local &locally relevant assets’

ALISSAsset

Mapping

assets

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

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……..

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

Conversation

so that support and services can be tailored for each person.

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.

Conversation

• Because introducing care and support planning involves changes to attitudes (mindsets), skills and clinic infrastructure.

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

tively

Russian

Community Resources and Assets (‘More than medicine’)

both uncommissioned and those sustained by responsive commissioning

tively

fessio

Arrangements

nal te

Conversation

The individual's perspective

scotland’s house of care. jungle the individual's perspective

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