Building the House of Care

January 2014

Martin McShaneJacquie WhiteEd Mitchell

Overview

• Context

• Principles

• Resources

• Discussion

2

• Context

• Principles

• Resources

• Discussion

3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Patie

nts (

%)

Age band (Years)

Morbidity (number of ETGs) by age band

0

1

2

3

4

5

6

7+

Number ofconditions

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.

Changing the nature of the conversation….the biggest challenge?

5

The soft stuff…is the hard stuff

6

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)

Year of Care Costs

7

Relationship between number of long-term conditions and cost

8

LTC Year of Care Programme

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

9

NHS Expo Seminar Domain 2

Gearing in activity into acute care

10

11

GP Specialist

1990

Specialist

2014

CARE GAP

Activity

Complexity

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

12

COMPLEX CARE PRACTICE

???

Bridging the gap

LTC Year of Care Programme

Impact of coordinated care

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

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

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

–Informational continuity–Management continuity–Relational continuity

17

The House supports:

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.

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)

20

Community Care Primary Care

GenHospitalseral

University/ Specialist Facilities

Social Care

GeneralHospital

ICare

The Future: 2014-2019

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

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)

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.

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.

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

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

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

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

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

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

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

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

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

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