shareddecisionmaking(sdm) ’...

Medical Clinics Ltd, Sussex Community Dermatology Service, Worthing Skin Clinic, R&F Emerson LLP of 13

Shared Decision Making (SDM)

Audit Results 2016

Introduction: Throughout 2016, the organisation has been developing and refining patient care pathways to developed ‘Shared Decision Making’ part of routine medical practice. As part of CQUIN’s performance measures, the objective of this report is to detail how Sussex Community Dermatology Service has continued to implement Shared Decision Making (SDM) into service delivery. This report shows progress made in comparison to Q2 in terms of patient engagement (involving a higher percentage of patients). We also summarise key changes made as a part of this ongoing commitment to the SDM process by the organisation.

Shared Decision Making is recorded at a clinical level around the needs of the patient based on a face-‐to-‐face discussion with the clinician, nurse or other healthcare professionals. Self-‐care plans have to be tailored around the disease, different treatment options, and patients wishes for engagement (some patients want detailed information and others may not). A tailored self-‐care management plan is then provided to each patient supported by a written copy sent to them at home with supporting information provided in clinic or after clinic as considered relevant subject to this discussion. The emphasis is on engagement of the patient in their care at all levels. This process is an ongoing process, which evolves as patients become more expert in self-‐management and the organisation adapts around these needs. At an organisational level, this involves administration and clinical decision making to support the changes that are necessary. This is facilitated by company management teams that meet each week to discuss changes and improvements to services at every level of administration, IT infrastructure, and clinical developments. The whole teams works together towards the same shared goal of improving care.

This audit report provides CWSCCG with evidence to show that during the third quarter of 2015/16, patients treated by Sussex Community Dermatology Service were actively involved the Shared Decision Making process throughout this process and as a result of changes made, the organisation has introduced process that support SDM.

1) Organisational Development of Shared-‐Decision Making Processes

As an organisation, we have spent many hours developing patient information leaflets, treatment advice leaflets, patient video’s on treatments we carry out, website links, and the development of standardised care plans that can be tailored to patients’ needs. These have to be written in a user-‐friendly way and the process is dynamic with a continued commitment to ongoing development.

The CQUINN has allowed us to focus on SDM as a core development objective over the past 12-‐months. This has included many hours of hard work developing the following:

• Patient-‐friendly information advice leaflets • Patient friendly treatment plans • Links to patient support groups and external information • Treatment videos on common investigations and procedures


• Programming of clinical electronic patient record screens • Incorporation of access to information ‘live’ for consultations across multiple community locations • Administration support for patient letters and communication

The development of many of these support aids and changes to clinical practice has taken many hours of work across the whole organisation. It also involved active engagement of patients in development of advice leaflets and consenting for video’s that are used to demonstrate treatments. Consent has to be obtained for filming and agreement that such materials will be accessible in the public doman for the benefit of other patients. Individual leaflets or videos can take 10-‐hours of planning, writing/filming, refining, and processing. Once completed, they have to be incorporated into the service and made accessible to the administration and clinical teams. Custom screens have to be built into the electronic database and staff have to be trained how to access the resources and incorporate them into consultations so that patients benefit. These resources then have to be made available across 21 locations that we provide patient services.

As an organisation we have been instrumental in developing technology to support these processes. We have built customised clinical and administration screens that make SDM accessible in a ‘live real-‐time’. We have many decision aids built into customised electronic patient record screens. These are available to all members of the team that are involved in day-‐to-‐day management of the patients journey from initial contact to eventual discharge and self-‐management. It is just as important that clinicians performing consultations have access to information as it is the medical secretary typing letters and SDM plans. They all need to use the same information resources in this process. This is facilitated through combined training at quarterly postgraduate meetings and day-‐to-‐day communication between team members including instant messaging across different locations. The IT team are based with the administration and clinical resources, so that they can incorporate changes as an integral part of clinical care. We have weekly development plans submitted by each team at company management meetings that engage the whole organisation.

2) Delivery of Shared Decision Making at a Clinical Level As an part of our commitment to SDM, we have developed systems that provide patients with three types of core care plans tailored around the wide-‐variety of presenting disease diagnosis and treatment options.

Patients are provided with one of three care plans:

-‐ Patient Self-‐Care Plan and Information -‐ Patient Self-‐Care Plan and Referral Specialist Nurse -‐ Patient Self-‐Care Plan and Patient Group Invitation

These are built into the customised electronic patient record screens enabling instant access to information resources during consultations. Patients can be shown ‘live’ information on different diseases, printed off information about their specific condition/treatment application, watch short videos on treatments, and these can all be accessed at a later date on our website areas that are purpose designed as a patient resource.


As a part of CQUINN’s, we have built many customised screens and incorporated many decision aids. Shared decision making customised screens provide link buttons to information sites, patient information leaflets, treatment leaflets, bespoke videos, and care plans.

Patient Video as a Part of Shared Care Decision Making

Patient video’s were filmed and edited over the past 18-‐months. All patients consented to them being made and to be used within the public domain as an educational resource for patients both within and external to the organisation. Written consent was taken in all cases. Videos are shared with partner commercial organisations as they helped finance the cost of filming and editing them. They include all common investigations and treatments such as patch-‐testing, skin-‐prick testing, cryotherapy, curettage & cautery, skin biopsies, cancer excisions, and skin flaps. These are accessed through ‘Quick-‐Link’ buttons on customised screens and every location has this available across clinics that we provide services.

The video on patch-‐testing has been viewed on YouTube® over 7000 times so the impact on patient care is not only direct but also helps to educate the public thereby improving patient self-‐management on a far wider public health scale: https://www.youtube.com/watch?v=RO9e54yusFg. Making them accessible via the internet allows patients to share information decision making with family members at home. We also recognise that this format of information may not be suitable for everyone or accessible to all if they have no internet access or have disabilities.


YouTube® Channel:

Example Videos


Patient Information/Self-‐Management Plans as a Part of Shared Care Decision Making

We have developed many patient advice leaflets on skin diseases, skin lesions, treatments, treatment applications, and post-‐care advice sheets. These are used as a part of SDM plans. They are especially useful for complex treatments or for use in treatments that may have associated morbidity before improvement is seen. Patients are frequently referred with sun-‐damage by their GP and self-‐management plans can be instrumental in educating both patients and primary care about self-‐management. This enables us to educate the patient population as a whole reducing unnecessary referrals into the system.

Example: Solar Keratoses Self-‐Management

A good example is the development of self-‐management plans for patients with sun-‐damaged skin (Solar Keratoses). Over 80% of patients with solar keratosis can be managed with topical treatments prescribed by their GP that include Solaraze® and Efudix®. All too often these treatments are not prescribed properly or patients’ fail to use them because they have received poor instructions or no instructions at all. Education at a primary care level helps in this process but has not proven successful at reducing referrals into secondary care.

When we provide patients with clear self-‐management and treatment advice leaflets, we also copy these care plans to GP’s. The majority of patients also keep a copy of recommended written treatment plans and should they develop further new lesions, care is sought directly from their GP avoiding a further referral into secondary care. Hence, self-‐management plans help to educate both the patient


and the primary care physician. This can help reduces unnecessary referrals into the system. It also enables us to discharge patients at an early stage with a care plan that allows self-‐management rather than booking further consultations. We can support the success of this process by the low follow-‐up ratio of the organisation compared to other NHS dermatology services. Our follow-‐up ratio is 1:0.6 compared to 1:1.3 i.e. for every 10 patients we see, we follow-‐up six patients compared to 13 in other local and national units. This has dramatic impact on reducing new patient waits making services more accessible for patients. We can demonstrate this low follow-‐up ratio across the whole service. We also have one of the lowest follow-‐up ratios in the UK for dermatology services.

Patient Support Group Links in Self Decision Making

In addition to the information leaflets provided in clinic, patients and clinicians can also access a list of common support groups. This list is actively maintained by the service and provides contact details and web links to local and national support services for a variety of conditions.


Audit Data & Results

In order to provide evidence that patients are actively involved in the Shared Decision Making process we have asked our clinicians to record information using our clinical system showing what type of care plan has been agreed with the patient.

Survey Results:

We captured 1,474 patients in the latest quarter audit. In this group, 87% had a recorded SDM plan recorded in the electronic prescribing record.

• 1,474 Patients have been surveyed to date • 55% had a care plan for skin lesions • 32% had a care plan for inflammatory disease • 13% Patients did not require a care plan (188 patients)

Simple disease diagnoses do not normally require a skin care plan as treatment may not be warranted. The consultation is mainly focused on making a diagnosis and providing patient information where considered necessary and relevant to care.

Skin lesion care plans typically involve diagnostic information, treatment advice, or prescribing application advice. The aim is to provide education for the patient, enable them to self-‐manage similar types of skin lesions, and seek treatment from their GP for future care if this is appropriate.

55% 32%

13%

Diagram 1 -‐ Has the paDent had a treatment prescribed or a skin lesion treated that required Shared Decision Making?

Skin Lesion Care Plan Skin Disease Care Plan No Care Plan Required -‐ Diagnosis Only


Inflammatory disease care plans tend to be more specific and tailored more towards the individual patient and their presenting disease/recommended treatment. Patient information is key to keeping patients informed and engaged about the possible options of treatment. If they engage, they are more likely to be compliant with medication prescribed or may choose not to have any treatment at all. For patients with more complex diseases such as psoriasis, there are often many modalities of care that can be offered to the patient including topical treatments, systemic treatments or light phototherapy. The provision of choice is important in these patients and by involving them in SDM, they are more likely to have a successful treatment outcome.

Of 471 patients who required a care plan for inflammatory skin disease (see diagram 2):

• 61% Prescribed Treatment & Education Only (290 patients) • 38% Self Care and Specialist Nurse Education (181 patients) • 0.4% Patient Group Invitation (2 patients)

Further analysis of this group of patients with inflammatory skin disease demonstrated that 62% of patients were managed through self-‐care and specialist nurse education with 38% just receiving prescribed treatment advice. Relatively few patients require ‘Patient Group Participation’ and this is perhaps to be expected as in the majority of cases, patient support groups tend to be recommended to those patients with more severe intractable and persistent disease. They have an important role to paly in more severe disease or in those patients with rare skin diseases.

62%

38%

0%

Diagram 2 -‐ Skin Disease Care Plan Responses Prescribed Treatment & Educajon Only Self care and Specialist Nurse Educajon

Pajent Group Invitajon


Key Findings

The audit data shows that clinicians have recorded the type of care plan produced on 1,474 patients. This is a 47% patient increase from Q2 to Q3 which suggests that the Share Decision Making processes and discussions at a clinical level have become increasingly frequent and a part of normal practice. Within this sample of 1,474 patients, 87% of clinicians reported that in addition to verbal patient information, they had supplied the patient with a patient information leaflet at the time of consultation. Further evidence of this is displayed in the Patient Satisfaction 2015 Survey results (See Diagram 3) in which 404 patients were asked the question ‘Were you given any written or printed information about your condition or treatment?’67% patients responded that they had received written or printed information about their condition and did not require anything further, 27% of the sample responded that they did not receive any patient information but did not require any and 6% of patients responded to the question that they did not receive any patient information but would have liked to have received some. Typical examples of the support given in the patient information leaflets which are given as part of the care plan include; wound-‐care advice, leaflets recommending patient support groups and information sources, leaflets about their skin problem or diagnosis and also contact details for the Nurse and Patient Helpline should they need to contact someone with any concerns or queries.

Of the two patients that were provided with Patient Group Invitations, these patients are supplied with the information of support groups, such as National Eczema Society and The Vitiligo Society.

Of the 471 care plans provided for patients with skin disease diagnoses, 290 care plans were provided in the form of a written care plan which included prescribed treatment and education only whereas 181 care plans were provided with self-‐care and specialist nurse instructions. This data provides evidence to support the theory stated in Q2 that the majority of patients are able to manage their condition themselves after receiving education from their clinician. Further confirmation of their care plan is provided in their patient letter, which provides guidance on how to apply or take medicines, the standardised personalised care plans can also be used in cases where the skin disease is common, e.g.

91%

8% 1%

Diagram 3 -‐ Were you given any wriQen or printed informaDon about your condiDon or

treatment? Yes, Definitely No, but I would have liked some No, but it was not required


eczema, psoriasis. The patient’s GP is also informed of this care plan, so that additional advice and support can be provided by them should the patient seek a consultation at their GP surgery.

During the Patient Satisfaction Survey conducted during September and October 2015, patients were asked the question ‘Shared Decision Making: Did you feel that the clinician/nurse involved you in the decision making process to choose your treatment and follow-‐up plan?’ (See diagram 4) Of the 363 patients that responded to the question, 88% of the sample (318 patients) reported that they were definitely involved in the Shared Decision Making process in partnership with their clinician, 11% of the sample (41 patients) reported that they were involved to some extent in the Shared Decision Making process for their treatment. 1% of the sample (4 patients) stated that they were not involved in the Shared Decision Making process for their skin condition. Of the comments from the patient satisfaction survey, none of the comments related to this question or were suggestions of how the patient wanted to be more involved in the decision making for their skin condition.

In addition to the findings above, the patient satisfaction survey also asked patients to respond to the following question ‘Were the reasons for any treatment or action explained in a way that you could understand?’ (See diagram 5 below). Of the 408 patients that responded to this question, 395 patients stated that the reasons were clearly explained to them during their consultation. 10 patients also responded that they did not need any information or no treatment was necessary during their appointment, 3 patients responded that the reasons for their treatment were not clearly explained however all procedures require a consent form before they can be conducted.

It is reassuring to see that less than 1% patients did not feel engaged in the share decision making process.

88%

11% 1%

Diagram 4 -‐ Shared Decision Making: Did you feel that the clinician/nurse involved you in the

decision making process to choose your treatment and follow-‐up plan?

Yes, definitely Yes, to some extent No


All patient information leaflets provided are also available on the website or the patients can request extra hard copies to be sent to their address. This supports the statement made in Q2 that patients’ families can access reliable information themselves, without needing to be present during the consultation. This is largely important in cases where patients may seek the advice and opinions of their families before making a decision about their care.

This audit is produced quarterly and allows Sussex Community Dermatology Service to continually reflect and improve patient access to reliable high quality skin care through the NHS in their local area.

Conclusion

The Shared Decision Making CQUIN is helping Sussex Community Dermatology Service to remain patient focused and engage patients in their own treatment pathway. Shared Decision Making has been introduced to every clinician working under Sussex Community Dermatology Service which provides further evidence of commitment and the investment Sussex Community Dermatology Service has made to continually provide a high level of reliable and quality care to all patients. Clinicians have supported the Shared Decision Making process on a clinical level by tailoring their patient letters to reflect the care plan criteria and changing their clinical practice to involve more discussion and exploring options with the patient during the consultation, this is recorded in the Shared Decision Making protocol designed by the software team of Sussex Community Dermatology Service. This has allowed for a large sample of patients to be included in the audit, where initially the target number of patients was 100.

It has also highlighted areas that are open to improvement such as the use of patient group invitations to local support groups and how this type of care plan can be increased in the future.

Above all we are pleased to see that increasing numbers of patients are involved with their care during consultations. There is evidence that patients are routinely receiving detailed and personalised care plans. The service is also keen to explore and develop further the use of educational videos for patients, as we feel that this can help patients to feel more confident and informed about the decisions they

Diagram 5 -‐ Were the reasons for any treatment or acDon explained in a way that you could

understand?

Yes, completely

Yes, to some extent

No

I did not need an explanajon

No treatment or acjon was needed


make with SCDS clinicians during their consultations. The audit data has also shown that an increasing number of patients are able to manage their own health conditions with the support provided by the clinician and also the GP; these findings are all useful tools as Sussex Community Dermatology Service continually improves the level of care provided to patients. In turn, we hope that this will also reduce referrals into secondary care through education of the patient and primary health care professionals.

Dr Sandeep Cliff Consultant Dermatologist and Medical Director

Dr Russell Emerson Consultant Dermatologist and Medical Director

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