integrated care matters #icmatters · anticipatory care planning in scotland thinking ahead and...
TRANSCRIPT
A movement for changewww.integratedcarefoundation.org @IFICinfo
Integrated Care Matters
#ICMatters
A movement for change
International Foundation for Integrated Care
IFIC is a non-profit members’ network that crosses
organisational and professional boundaries to bring people
together to advance the science, knowledge and adoption of
integrated care policy and practice.
The Foundation seeks to achieve this through the
development and exchange of ideas among academics,
researchers, managers, clinicians, policy makers and users
and carers of services throughout the World.
A movement for change
‘Integrated Care Matters’
Monthly Webinars
• User and carer perspectives
• Home and Away presentations
• Facilitated Discussion – add questions & reflections to chat box
• Knowledge Tree - Topic based resources developed for each session – send your resources to Marie: [email protected] for uploading. A copy of this will be sent out to all registered following the Webinar today
• SIGs are in development and will be hosted on the IFIC Website, if not already done so, please sign up for IFIC membership – a community membership is free if you don’t want to join as a full member
• Up and coming Webinars
• Webinars are in collaboration with UWS, Alliance & HIS
Anticipatory Care Planning in Scotland
Thinking Ahead and Making it Happen
Stuart Cumming, ACP LeadJanette Barrie, ACP Lead
November 2016
Stuart Cumming Janette BarrieJanuary 2017
The ACP Team
Stuart Janette Sheila
Overview of the Session
• Recognise and share where we are
• Describe the priorities in the National Action Plan for Anticipatory Care Planning (ACP) in Scotland
• Outline current tests of change
• Facilitating a whole system approach
• Measuring impact
Quick recap...how we got here
ACP Task and Finish Group
Improvement Collaboratives
Living Well in Communities
NationalACP Programme Board
National Action Plan for ACP
What is ACP?
Alice’s Story and ACP Mattershttps://www.youtube.com/watch?v=GXeJKlSL4kA
https://www.youtube.com/watch?v=gHzJ_3Z7lwk
•It’s about Thinking Ahead•It’s Proactive Person Centred Care•It’s working with people and those close to them•Helping People to understand their conditions and situation•It’s about having the right conversations to make informed decisions•It’s an iterative process•Right thing is done at the right time, for the right person with the right outcome every time.
National Action Plan for ACP Ensure delivery of ACP for all who would benefit :
1. Raise awareness and profile of ACP and mainstream ACP principles within health and care
2. Share InformationSupporting people to develop their planDesign ACP material for individualsFocus on early intervention
Supporting professionals to work togetherIncrease access to the Key Information Summary (KIS)
3. Work to ensure carer support aligned with ACP
Trajectory Onset
Crises Phase
Acute Phase
Stable Phase
Unstable Phase
Downward Phase & Frailty
Dying Phase
Making it Happen- Recognising opportunities (Adapted from McCorkle& Pasacreta 2001)
ACP Opportunity
ACP Opportunity
ACP Opportunity
ACP Opportunity
ACP Opportunity
ACP Opportunity
ACP Opportunity
ACP Opportunity
https://www.youtube.com/watch?v=GXeJKlSL4kA
Think Ahead Think ACP- ACP Triggers-Condition Situation and Assessment
• Elderly and living alone
• Housebound people of all ages
• Complex physical, mental health or social support needs
• Infants, children and young people with complex and palliative care needs
• Unscheduled care access
• Carer stress
• Condition(s) specific (disease registers)
• Risk predictive tools (SPARRA, frailty, complexity, Lifecurve)
• Collaborative assessment
Raising the Profile
• National Workshops
• ACP Programme Board
• Networking across Scotland
• International Foundation
of Integrated Care
Working with the Scottish Government
Primary Care
Mental Health
CHAS &Childrens
Services
Local Authorities
The Alliance
Advocacy
Palliative Care
Carers
UnscheduledCare
Scottish Government
Scottish Care
LWIC
Housing
SCVO Older PeoplesServices
Health Inequalities
Technology
Collaboration
Rehab Teams
Public Health
ACP Is
Everyone’s Business
Person-centred carewith personal ownership
Developing Support Material
Documents and Apps
Tests of Change
Advocacy
Developing and Testing Documentationand App
Power of Attorney
Identifying vulnerableindividuals
Early intervention
Ways of Working
Care Homes and Care Inspectorate
ProfessionalEducation
Media
KIS and ECTP
8.4%
4.1%
4.9%
5.9%
4.4%4.1%
3.5%
7.3%
6.6%
4.5%
5.5%4.6%
6.5%4.4%
Current % of ACPs per population
Key Information Summary...The value of a KIS....?
Potential 30-50% reduction in admission
Proposed change measures:
• Number of ACPs and KISs
• Number of Power of Attorneys
• Admission/readmission rates
• Bed days and delayed discharge
• Percentage of last 6 months of life spent in hospital
• Workforce engagement
• Patient and carer/family experience
Measure change through Contribution Analysis
Growth and Change
• Learning Needs Analysis to develop education programme
• Whole system communication programme• Raise professional and public awareness and
engagement
• Link with Technology Enabled Care Improvement Programme
• Mobile technology (Apps) • Improve use of eKIS
Thank you for listening.
For more information please contact us on the email addresses below.
Multidisciplinary Anticipatory Care Planning: A model to support Integration
South Ayrshire Health and Social Care PartnershipDr Ajay KoshtiClinical Lead SA H&SCP
Background
ACPs in the context of QOFPrevious Studies-Nairn Study, AberdeenshireJury is still outCurrent focus –
•National Clinical Strategy, •TQA for GMS•HSCP planning process
Project map
• Pre-pilot work
• Pilot test
• Roll out – 1st ACP event- 6th September 2016
• Review - 2nd ACP event- 6th December 2016
• Final Review- planned for March 2017
Approach to this project
We hear what you say- what matters
•People•Relationships•Culture•Processes
Good enough plansDistributed leadership
South Ayrshire HSCP PilotMDT
•GPs•DNs•ICES•Social Worker•CW and Telehealth•Long term conditions team•CPNs•Acute sector•Pharmacist•Patients/ relatives/ carers
Regular meetingsPre-selected patients and work upDiscussion around
•What can be done to improve care at present•What can be put in place in the event of anticipated crisis
• Explore issues, find solutions and agree action plans
Project Outline
• Identify timetable of dates/times for MDT• Members/attendance at each MDT meeting• Identify patients to select • Involve patient, family and carers• Commence ACP• Consider co-ordinator/lead case manager• Consider Evidence Based Intervention• Document in ACP• Sharing the ACP• Regular review and referral
ACP Process
• to directly relate activities with the expected outcomes
• to demonstrate the impact of activities• to assess the "if-then" (causal) relationships
between the elements of the program
Logic Model Approach
Inputs Activities Outputs Outcomes (impact)
Resources Invested in programme
Activities undertaken What is produced through those activities
The changes or benefits that result
e.g funding, staff, time e.g training, education e.g number of staff trained
e.g increased skills/knowledge
Logic Model
• Quantitative and qualitative data collection
• Keep to a minimum for practices
• Extract and analyse as much as possible centrally
• Some to be captured routinely to make it less labour intensive
• Share at future workshops
Data Collection
• MDT ACP numbers – EMiS report run centrally –
practices to apply read codes using template provided
• MDT Meetings register – practices to record details
of meetings and participants as well as numbers identified/reviewed for ACP
• MDT ACP Quality – practices to audit small cohort of
ACPs (before, 3mths, 1yr) using audit tool provided
• Patient Story– MDTs to produce a case study using
template provided, prior to future workshops
• Staff experience– Baseline about current working, then
again once MDTs established and running a few months
• Patient experience – cohort of patients with MDT ACP
to be invited to participate in a focus group to give feedback
What, How, When, Who
Learning from the ACP Pilot at Tam’s Brig
• Dr Callum McCabe – GP• Karen Kerr ANP• Kate Hollins – District Nurse Team Leader• Carolyn Doherty – Social Worker
Group Discussion
1. How are you going to engage with key stakeholders in the MDT?
2. What support do you need from your link facilitator?
3. How are you planning to make this work?
Progress so far
Tam’s Brig PilotACP roll out event – Sept 6th
13 Teams participatingProgress so far, Who and How, Stories, ChallengesNational contextInformInfluence
Key questions
What can be done now?
What are the anticipated events?
Action plans with full participation
Communication
ACP Baseline Audit
• Practices asked to audit 10 existing ACPs
• Audit conducted October 2016
• 17 audit questions
• Answer Yes, No or n/a (eg n/a if question not relevant to that particular patient at that time)
Audit Questions• Is the renewal date documented? • Lead professional for the individual patient is stated? • Diagnosis and relevant medical conditions are documented? • Are anticipated problems documented? • Is there a self management plan in place? • Is there clear guidance documented on what the person wants to happen in the event of
deterioration?• Is there clear guidance documented on what the person does not want to happen in the event of
deterioration? • Carer/NOK /name and contact details documented? • Key holder for patient’s home or Key safe number is documented? • Other professionals involved in the patients care are stated (SW/DNs/Hospice etc)? • Patients preferred place of care is stated? • If appropriate; preferred place of death is stated? • DNACPR status documented? • AWI in place or evidence that capacity has been addressed? • Evidence of good conversation of what is important to person and his/her family? • Does the patient have a hand held ACP ? • Is POA/Guardianship in place?
ACP Baseline Audit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11
GP Practice
Lead Professional is stated in ACP
ACP Baseline Audit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11
GP Practice
Anticipated Problems documented in ACP
ACP Baseline Audit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11
GP Practice
POA/Guardianship in place?
ACP Baseline Audit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11
GP Practice
Self-Management Plan in place
ACP Baseline Audit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11
GP Practice
DNACPR Documented in ACP
1ST MDT ACP Audit
• Practices asked to audit 5 MDT ACPs
• Audit conducted November 2016
• Same 17 audit questions as baseline audit
• 40 ACPs audited in total
Audit Results
0%10%20%30%40%50%60%70%80%90%
100%
Audit Question
ACP Baseline and 1st MDT ACP audit Baseline Audit
1st MDT
Number of patients reviewed to date
• Total of 105 patients from 9 practices have been identified, reviewed and coded – 47 (52.4%) female, 35 (35.2%) male (12.4% gender not
known)
– 37.1% less than 75 yrs of age
– 50.5% patients 75+ years of age
– 12.4% age unknown
• NB - EMiS practices code patients using MDT ACP template (read code 98G0)
Patient Case Studies
• Dr Mudunuri
• Anne Love
Group Work
• In your group consider
– Progress so far
– Relationships
– Challenges
– Solutions
Key Learning Points
• Design Factors– Meeting schedules
– Co-ordination
– Systems – INFORMATION SHARING
– Processes
• Excellence Factors– Relationships
– Ownership
– Collaboration
– Dependency and links with other systems
Workshop 3
Please note workshop 3 is on
Tuesday 7th March
12noon – 3pm
Kylestrome Hotel, Ayr
• Thank you
• Questions?
A movement for change
Virtual Blether – What Matters with Mandy Andrew
Mandy Andrew
iHub Network Development Lead,
Healthcare Improvement Scotland
A movement for change
Anticipatory Care Planning
Knowledge Tree
A movement for change
Webinar Dates for Your Diary
• House of Care Feb 9th
• Enhanced Interdisciplinary Care in Localities Mar 15th
• Community Centred Palliative Care April 19th
Volunteer presenters for future webinars welcome
Contact: [email protected]
A movement for change
Stay connected and grow our Integrated Care Matters
Learning Community
• Join us at:
• Tweet #ICMatters
• Blogs – share your thoughts and experience
• Knowledge Tree: Add your resources and grow our tree.
Send resources to Marie at: [email protected]
• Involve your colleagues in future webinars
• Visit the WHO portal http://integratedcare4people.org/
Thank You
