understanding patient perspectives of the ... - greenwich ccg · contract using the year of care...
TRANSCRIPT
Understanding patient perspectives of the Year of Care model
June 2015
www.pickereurope.org
Picker Institute Europe
Picker Institute Europe is an international charity dedicated to ensuring the highest quality
health and social care for all, always. We are here to:
Influence policy and practice so that health and social care systems are always centred
around people’s needs and preferences.
Inspire the delivery of the highest quality care, developing tools and services which
enable all experiences to be better understood.
Empower those working in health and social care to improve experiences by effectively
measuring, and acting upon, people’s feedback.
© Picker Institute Europe 2015
Published by and available from:
Picker Institute Europe
Buxton Court
3 West Way
Oxford, OX2 0JB
England
Tel: 01865 208100
Fax: 01865 208101
Email: [email protected]
Website: www.pickereurope.org
Registered Charity in England and Wales: 1081688
Registered Charity in Scotland: SC045048
Company Limited by Registered Guarantee No 3908160
Picker Institute Europe has UKAS accredited certification for ISO20252: 2012 (GB08/74322)
and ISO27001:2005 (GB10/80275). Picker Institute Europe is registered under the Data
Protection Act 1998 (Z4942556). This research conforms to the Market Research Society’s
Code of Practice.
Contents
Executive summary 1
1. Introduction 3
Background 3
Aims of the research 3
Method 4
2. Current experiences and priorities 5
Current experiences 5
Factors which are important for management of LTCs 5
3. Reactions to the Year of Care model 8
Initial reactions to YoC model overview 8
Reactions to specific aspects of the YoC model 8
4. Conclusions 12
Appendix 1: Topic guide 13
©2015 Picker Institute Europe. All Rights Reserved. 1
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
Executive summary
©2015 Picker Institute Europe. All Rights Reserved. 2
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
©2015 Picker Institute Europe. All Rights Reserved. 3
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
1. Introduction
This report outlines findings from qualitative research with patients with long term conditions
(LTC), exploring their views and experiences of care and support planning. The purpose of
the research was to inform the design, delivery and monitoring of the new extended LTC
contract using the Year of Care model, which will be delivered in Greenwich from June 2015.
BACKGROUND
From June 2015, provision for people with long term conditions in Greenwich will be
organised under a new extended contract using the Year of Care model. This model aims to
provide a framework for personalised care; specifically by providing:
support for self-management;
patient engagement in decisions about their care;
coordination of health and social care; and,
emotional, psychological and practical support.1
The Year of Care model incorporates a number of elements to support care planning for
people with long term conditions. This includes:
Annual screening appointments covering a wide range of checks and measurements
Results from these tests sent to patients in advance of a follow up appointment to
discuss care planning
Results provided alongside contextual information and prompts to consider topics for
discussion during the follow up appointment
A second appointment to discuss issues raised by the test results, alongside any wider
issues affecting patients, and decide treatment options
Key decisions from this consultation documented in a Care and Support Plan, to help
patients manage and review their condition
The Picker Institute was commissioned to undertake research with patients with specific long
term conditions, to better understand their current experiences and explore their views about
the Year of Care model. Findings from this research form the basis of this report.
AIMS OF THE RESEARCH
The overarching aim of the research was to understand the needs of patients with long term
conditions, specifically in relation to care and support planning.
Specific objectives for the research were to:
Explore views about current provision for managing long term conditions
Gather views about the Year of Care model
1. www.yearofcare.co.uk
©2015 Picker Institute Europe. All Rights Reserved. 4
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
Understand what other support patients with a long term condition may want
The intention is that findings from this research will be used to inform the design, delivery
and monitoring of the new extended contract for provision for people with long term
conditions, which will be delivered in Greenwich from June 2015.
METHOD
Findings are based on six focus groups with patients with specific long term conditions –
diabetes (two groups), COPD, heart failure, and hypertension (two groups). Participants
were recruited using varied approaches – attending existing patient group meetings
(diabetes), opt in recruitment via existing services (COPD, heart failure), and professional
recruitment using free-find techniques (hypertension). The groups varied widely in number
(from 2-15 participants), with a total of 38 people across the six discussions.
All discussions were structured with the aid of a topic guide (see Appendix 1).
It is important to note that this study was qualitative in nature, designed to provide rich data
about the range of views and experiences of these groups and to highlight any patterns and
typologies where they occur. Participants were purposively selected to ensure the widest
possible range of views were included. The research is not intended to provide statistical
data about these groups, or be representative of the unregistered population.
Verbatim quotes are used throughout the report to illustrate key points and findings. These
have been anonymised and all names and locations have been changed to protect people’s
identities.
©2015 Picker Institute Europe. All Rights Reserved. 5
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
2. Current experiences and priorities
This section outlines views and experiences of current provision for long term conditions, as
described by those who took part in the research. This includes a focus on issues
considered important for managing long term conditions.
Current experiences
Participants’ experiences of LTC provision varied considerably, with substant ial differences
identified between conditions:
COPD – Fairly extensive support from specialist community teams, with minimal
involvement from their GP
Heart Failure – Cardiac clinics at a GP surgery (not their own) with frequency of
appointments varying according to need
Diabetes – More diverse experiences, including specialist clinics in hospital,
specialist nurses in GP surgery clinics, or wholly GP-managed care
Hypertension – Little or no specialist support, with ad hoc monitoring and
management by GP practice nurse
Satisfaction with existing provision also varied, with individuals from all groups highlighting
examples of both good and poor care. Across the groups, however, patterns of views
suggested a link between satisfaction and whether or not people received specialist
services, and the extent to which they felt part of a co-ordinated package of care. For
example, the comprehensive support provided by the specialist COPD team was widely
praised, while the typically less extensive support for hypertension was viewed by some as
insufficient.
“Like lots of people who have a chronic illness, you tend to pick up others, like
diabetes and so on and so forth. But for the COPD team, I must say they are
absolutely fantastic and I’m learning stuff that I never knew about the… chest, never
knew about the question of exercise. Now at this stage in Greenwich, you don’t have
this sort of fall back if you have a problem with high BP.” (Hypertension group)
“Basically, you go to the doctors and it’s like, ‘here’s your tablets. I’ll phone you in a
few months and you can have your BP taken again’. There ain’t no, ‘why don’t you
come and talk to this nurse, she could change your lifestyle’. There’s none of that. It’s
‘here’s your tablet, get on with it’.” (Hypertension group)
Factors which are important for management of LTCs
People were asked to consider which factors help and hinder the management of their LTC,
and how they would ideally like to manage their condition. Responses highlighted a number
of key issues:
©2015 Picker Institute Europe. All Rights Reserved. 6
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
Relationship with healthcare professionals (HCPs) – People valued having
time to speak with a HCP about their concerns, feeling listened to and being
involved in decisions about their care. They wanted HCPs to be approachable,
treating them as a complete person with often multiple needs, and helping them
consider a range of treatment options, rather than simply prescribing medications.
“My GP is fantastic… you can talk to her.” (Hypertension group)
Continuity of care – While people expressed a preference for having a single
point of contact where possible, good communication between teams and HCPs
was equally valued. Having to repeatedly explain your medical history was
considered a waste of limited appointment time, and implied that records were not
being kept or used properly.
Accessibility – People wanted to access care when needed, and variable
experiences of service accessibility prompted strong feelings. In particular, long
waiting times for GP appointments, being unable to see their GP of choice, and
constrained length of GP appointments were cited as important barriers to
managing LTCs. This contrasted with positive experiences, such as longer
appointments with practice nurses, and the responsiveness of the COPD
specialist team emergency care, which were highly valued.
“I have actually got a very, very good doctor… but when I last phoned up to discuss
my BP and possibly thinking about changing medication, the earliest appointment I
could have was a month later.” (Hypertension group 2)
“I’ve got a named person [in the COPD specialist team] that I can ring up and if I
have an issue they will come out and see me, and very often on the same day. That’s
been fantastic. I hope I am not going to hear that that is going to change.” (Diabetes
group 1)
Information – People typically wanted to be informed about their condition and
the treatment options, both verbally so they can ask questions, and in written form
so they can take things in at their own speed and consult with others if necessary.
Crucially, any written information needs to be clear and jargon-free.
Ongoing monitoring and reviews – Proactive contact from HCPs, such as
appointment reminders and follow up letters, were appreciated; as were regular
clinics and review opportunities. Where this was not happening, people expressed
concerns that their condition was not taken seriously and that problems could be
missed. Care plans were raised spontaneously as a way to clarify next steps. This
was despite only a small number of COPD patients referring to existing care
plans.
©2015 Picker Institute Europe. All Rights Reserved. 7
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
“GP’s the first line, they’re supposed to contact the diabetic person every six months
or whenever the check-up is due. They’re supposed to send a letter or contact, but
they don’t. You have to contact them to make an appointment to see the nurse.
That’s got to be improved. Everything’s on computer. They have all the details.”
(Diabetes group 1)
Specialist knowledge vs. holistic care – People wanted to know that key HCPs
understood their condition and treatment options, but also wanted to be treated
holistically; for example, understanding co-morbidities, drug interactions, and
associated lifestyle issues. This ideal combination of specialist and
comprehensive care was acknowledged to be difficult, particularly for GPs dealing
with patients with often complex co-morbidities. However, examples of wide
ranging services being coordinated by specialist teams, such as the COPD team,
were highly praised.
“What GPs are doing is falling between two stools. On the one hand, expertise about
certain conditions and on the other hand, actually looking at you holistically, looking
at you as someone who will have a number of particular issues, and neither can
really be addressed at the moment… Sometimes the GPs are saying things that are
just not the case.” (Hypertension group 2)
Non-clinical support – Various forms of financial, physical and emotional support
were deemed to be important for managing LTCs; for example, help with claiming
benefits, accessing specialist equipment, and identifying support groups.
Participants cited positive examples of these supports that enabled them to better
manage their own care – such as learning to manage stress and anxiety, how to
monitor their own foot health, and receiving support with diet and exercise.
“When we used to have the clinics in the hospital when they used to check
everything, then once a week we used to have a session, everybody sit down and tell
us about the diet, about the food… you can learn about things like that.” (Diabetes
group 2)
©2015 Picker Institute Europe. All Rights Reserved. 8
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
3. Reactions to the Year of Care model
This section outlines people’s views about the Year of Care model, including initial reactions
to an overview of the model, and more considered reactions to specific aspects of the model.
Initial reactions to Year of Care model overview
A brief film outlining the key principles of the Year of Care model was shown to participants,
prompting mixed reactions. Views were primarily split by condition, with participants in the
hypertension groups broadly enthusiastic, seeing this model as providing more structured
support than they currently received. Conversely, some participants in the COPD, heart
failure and diabetes groups expressed concerns about losing specialist care under the new
model; in some cases, viewing the model as a cost-cutting exercise, passing management of
care from specialist teams to already under-resourced GP practices.
“You come up here [hospital] every year, normally it’s a six month period. You see a
consultant, have your tests done, get your results, a nice big sheet of the results. T he
results are then sent to your GP. What I want to know is, is this going to take a part of
that [away]? Because if it is, it’s going to be a total cock up. It’ll be a mess.” (Diabetes
group 1)
“They are trying to make a one size fits all… That’s part of the cost-cutting stink. And
one size doesn’t fit all. One size doesn’t even fit the same foot, because his condition
is different to mine, even though it’s the same name.” (Heart failure group)
However, this is not to say that views were consistent across conditions. Indeed, the broadly
enthusiastic hypertension groups included people with comorbid conditions such as COPD.
This suggests the importance of the context within which the model is discussed –
specifically, whether it is seen as something that is adding to or replacing existing care.
Reactions to specific aspects of the Year of Care model
In order to move beyond people’s knee-jerk reactions, discussions focused in more detail on
three distinct aspects of the Year of Care model: the initial assessment with a nurse or
health care assistant; the diagnostic information sent to patients; and the subsequent GP
consultation.
Initial assessment – The annual (or biannual) assessment was seen as an
improvement for those who were not already part of a regular testing or review
programme. For others, there were concerns that this was duplicating (or worse,
replacing) existing processes in separate specialist teams that currently worked well.
“I see the COPD nurse in the surgery once a year. The results go to the GP because
he’s in the same building. It all goes on my records, and as I say, I see the cardiac
©2015 Picker Institute Europe. All Rights Reserved. 9
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
nurse every month and that goes onto my records. It’s not broke.” (Heart failure
group)
In spite of these mixed views, people typically welcomed the idea of combining
multiple tests in a single appointment. Experiences of attending multiple
appointments in different locations were described as draining and inconvenient,
particularly for people with complex comorbid conditions.
“People with several conditions at once, that in your life you could actually really
come across a time when you’re in hospital two days a week, then GP, and you look
at your time in your diary and you can’t actually do anything. It just saps your energy.
It just takes so much out of you because you can’t effectively work with so many
things.” (Hypertension group 2)
However, there were questions about how combined testing would work in practice.
In particular, participants sought clarification about which conditions and tests would
be included, with concerns about whether these would be broad enough, and
whether the time allotted would be sufficient. There were also questions about the
expertise of the nurse or health care assistant in being able to carry out multiple
tests, and whether or not these tests could be undertaken in one location given the
range of equipment and skills required.
Diagnostic information – Access to test results was not currently widespread, with
people tending to hear only whether their results were normal or abnormal, and often
from a non-medically trained receptionist. For many, receiving written information
about test results was therefore a welcome change, affecting the balance of
information between doctor and patient during consultations. Combining test results
was also felt to be useful for encouraging doctors to look across conditions, rather
than focus on single issues. Having results in written format was particularly useful
for people who struggled to take in information during appointments, allowing them
time to process the information and consult with others.
“I like [having a written record] because, where I suffer from mental illness, I can walk
into the doctor’s surgery and he can talk to me for 10, 20 minutes and by the time I
walk out of there I don’t remember a word of what he’s just said… But with having
this here, I can take this to my family and say, ‘This is what they’re saying. Can you
help me understand it? Can you help me do this?” (Hypertension group)
Yet, there were a number of participants who felt this information was unnecessary,
preferring to rely on the expertise of HCPs to interpret results. One participant,
however, subsequently acknowledged that this view may reflect his fear of change
rather than a lack of interest in receiving information.
©2015 Picker Institute Europe. All Rights Reserved. 10
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
“[Test results are] academic interest only… If my cholesterol was creeping up I would
expect that whoever health professional was monitoring that would bring it to my
attention. I’m an electronics engineer. I give my health care professional a promise. I
won’t tell her how to look after my health, if she doesn’t try and fix my telly. She’s the
expert, not me… and I trust her.” [After a reminder about favourable comments
previously made about receiving written information from a cardiac nurse] “Yeah, ok,
yeah. I’m a bit resistant to change I think.” (Heart failure group)
There were also concerns that providing detailed test results could cause alarm,
particularly among those with declining health or those less able to understand the
results due to language and literacy issues, or general frailty. This was countered to
some extent by the explanation and benchmarking information provided alongside
the results, which were generally found to be useful. Although, participants wanted to
know that people with particularly bad or unexpected results could discuss these
immediately, rather than be left to dwell on the results before the appointment.
“Like my doctor will say something to me, like high blood pressure, or other medical
conditions, but not explain it, so I’ll go home and look on the internet and self -
diagnose, and everything comes up the worst, you know what I mean. So having it
there and explained properly is a lot easier to take in.” (Hypertension group)
“One of my concerns would be if you got that and you are in the abnormal category
on more than one issue. I can see that being difficult for the patient concerned of
having to wait another 10 days or more to see your GP.” (Diabetes group 1)
The prompts for topics to discuss with the GP included with the diagnostic
information were generally seen as helpful, replicating what some people tried to do
themselves prior to appointments. The list of possible topics was comprehensive,
giving people permission to talk about issues other than medication without feeling
they are wasting a doctor’s time. However, there was some concern that GPs would
either ignore the selected topics or not raise important topics because they had not
been circled by the patient.
Consultation (incl. shared decision-making and goal setting) – The idea of
having more time with a GP to review results and a written framework for discussing
care options was broadly welcomed. People also acknowledged the benefits of
reviewing patients holistically, looking across multiple conditions. Indeed, for those
with fairly limited opportunity to review their condition, this was strongly supported.
Yet, earlier concerns about whether this would be additional to or a replacement for
existing provision were raised again. In particular, people questioned whether GPs
would have sufficient time, skill or expertise to manage often complex conditions.
These concerns were largely driven by people’s perceptions of GPs services, as wel l
as their views about their current LTC provision. For example, experiences of
struggling to get appointments with GPs suggested that the service was already
©2015 Picker Institute Europe. All Rights Reserved. 11
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
overburdened, with a lack of time to cover these additional reviews in sufficient depth.
For those with a poor relationship with their GP, it was difficult to envisage having a
productive conversation, particularly given the personal nature of some of the topics.
Furthermore, for those with valued specialist services, there was a sense that GP
reviews would either add unnecessary duplication or result in the loss of existing
provision.
“I think it’s possible. I think [the model] might work very well, big improvement. [BUT]
I don’t think this is going to get sorted until GPs have more time.” (Hypertension
group 2)
“A lot of us have different illnesses, but I will assure you that I have not been to see
my GP about COPD for a long, long time because everything is sorted. If I have a
problem [the COPD team] are around in a car, usually within an hour… so the GP
has not had to have any appointments for a number of years about my chest.”
(Hypertension group 2)
Goal setting was a particularly controversial aspect of the model, with views divided
between those who welcomed the impetus to improve their health, and those who
found it challenging. For the former, goal setting was seen as a way to get both
patient and doctor to work together, drawing in support from GPs with wider issues,
such as diet and exercise. There was also the potential sense of achievement, and
even praise from GPs, if goals are met. For others, goal setting was at best an
irrelevant exercise covering ground that would have been considered elsewhere. At
worst, it could be detrimental for certain people, such as those with mental health
issues, applying external pressure on often deeply personal issues. These concerns
prompted discussions about whether this element would be optional, and whether
there would be consequences of not meeting agreed goals, such as damaging the
GP-patient relationship or even restricted access to treatment (Qp58).
“I can see this being used against you.” (Heart failure group)
“Let me give you an example. Maybe you have gone to your GP. There are
expensive medications and your GP has looked at it and thought it best you go to the
gym rather than maybe prescribe the drug… If they do opt out, are they going to
continue with that expensive medication or not?” (Hypertension group)
©2015 Picker Institute Europe. All Rights Reserved. 12
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
4. Conclusions
Overall, these findings suggest that the principles of having regular reviews with shared input
into care plans for managing LTCs are broadly welcomed; particularly if they look at people
holistically and cover multiple conditions. The model was especially well received by those
who currently have limited opportunities to review their care.
Indeed, many of the factors identified by participants as being important to managing their
LTCs are intrinsic elements of the model – time to discuss care options; being involved in
decision-making; being treated holistically; access to information and support for self -
management; opportunities to review and monitor care.
Yet, the wide ranging and often emotive responses to aspects of the model highlight the
importance of the context into which the changes would be applied. People’s views about
their current provision are fundamentally important, as are their perceptions of the GP
services which would be required deliver the new model. Change can be unnerving,
particularly so for those who currently feel secure in their care and/or have concerns about
whether GPs would be able to deliver the new model. For many, this prompts a number of
questions:
What will this change mean for my care? Do I stand to gain, or lose out?
Why is it being proposed? Who is it for? – Is it for patients, to improve care? Or to
save money?
How will it work in practice? – Which conditions will be included? Will the
healthcare professionals involved have the right skills, time and resources? Wil l I
be able to choose who I see? Will I be able to opt out if I want to?
Whether people think they will personally benefit or lose out from these changes inevitably
drives their views about the model as a whole. Fear of losing out – either by losing access to
valued services, or having to take on additional burden – can be distressing, and further
support may be required to reassure people about how the model will work in practice.
©2015 Picker Institute Europe. All Rights Reserved. 13
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
Appendix 1: Topic guide
NHS Greenwich CCG: LTC patient engagement
TOPIC GUIDE
The overarching aim of the research is to understand the needs of patients with long term
conditions, specifically in relation to care and support planning. This research will inform the
design, delivery and monitoring of a new extended LTC contract, that will be delivered in
Greenwich from April 2015.
Specific objectives for the research:
Explore views about current provision for managing long term conditions
Gather views about the Year of Care model
Understand what other supports patients with a long term condition may want
1. INTRODUCTION
Introduce self, Picker Institute – an independent charity dedicated to ensuring highest
quality healthcare for all
Research commissioned by NHS Greenwich CCG – NHS organisation responsible for
organising healthcare services in Greenwich
Background about the research – to explore patients’ views about proposed changes to
care planning for people with long term conditions (see box above for more detail)
Confidentiality – all responses are anonymous; personal details will not be recorded or
passed outside the research team
Recording – conversations recorded for quotes; no personal details will be recorded; no
detailed attribution when reporting
Discussion ground rules – want to hear views / experiences / opinions; no right, wrong
answers; no speaking over each other (for sake of recording); lots to cover and want to hear
from everyone, so may need to move things along occasionally
2. BACKGROUND AND WARM UP – explore briefly
Introductions – participants to introduce themselves
o Name
o Who live with
o What their interests are
Ice-breaker – TBC…!
3. CURRENT PROVISION
©2015 Picker Institute Europe. All Rights Reserved. 14
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
Explore views about current provision
o How do they manage their condition
PROMPT: role of GP; community health services; support organisations; friends /
family; other
o What helps / hinders how they manage their condition
PROMPT: Relationship with GP; access to support; information; care plans
Explore principles for managing long term conditions
o How do they want to manage their condition – spontaneous at first, then PROMPT:
PROMPT: Being involved in decisions; being informed about medications,
treatments, risks, side-effects, etc; opportunities to review treatment;
coordination of support; receiving emotional support; support with managing
comorbidity issues; relationship with professionals; support for family and
carers; other
o Which principles are the most important, and why
[If appropriate – could do this as a prioritisation exercise – or could just ask if there’s one that’s more
important than another]
2. OVERVIEW OF YEAR OF CARE MODEL
PRESENT 3 MIN VIDEO
READ and HANDOUT SHOWCARD A: Overview of Year of Care Model
Explore reactions to overview of Year of Care Model
o What do they understand about this model
o Do they have any questions about the model [NB may not be able to answer these, but
will pass them on to CCG team]
o What do they think about this model
What do they like about it, and why
What concerns do they have, and why
o How is this model different, if at all, to their current provision
3. SPECIFIC ASPECTS OF THE YEAR OF CARE MODEL
Explain that we are going to provide a little more information about three aspects of the model,
and ask their views in relation to each
Explore views about annual / biannual consultation with nurse
o READ and HANDOUT SHOWCARD B: Nurse consultations
o What do they understand about this aspect
o Do they have any questions about it
o What do they think about this aspect
What do they like about it, and why
©2015 Picker Institute Europe. All Rights Reserved. 15
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
What concerns do they have, and why
o How is this aspect different, if at all, to their current provision
Explore views about diagnostic information
o READ and HANDOUT SHOWCARD C: Diagnostic information
o What do they understand about this aspect
o Do they have any questions about it
o What do they think about this aspect
What do they like about it, and why
What concerns do they have, and why
o How is this aspect different, if at all, to their current provision
Explore views about GP consultation
o READ and HANDOUT SHOWCARD D: GP consultation
o What do they understand about this aspect
o Do they have any questions about it
o What do they think about this aspect
What do they like about it, and why
What concerns do they have, and why
o How is this aspect different, if at all, to their current provision
o [If not already covered] How would they feel about being involved in planning their
own care in this way (shared decision-making)
How comfortable do they feel about discussing care planning with their GP
What information / support would they need to feel able to input into these
discussions – information about what; in what format; by whom (e.g. written
info about medication side-effects; discussing lifestyle factors with a nurse etc)
PROMPT: information about medications, side-effects, lifestyle, co-
morbidity; treatment risks and benefits
o [If not already covered] How would they feel about setting goals for their care (goal
setting)
How helpful do they think setting goals would be
What information / support would they need to feel able to set goals
How should the goals be used going forward
PROMPT: reviews, coordination with other support / care plans, other
2. REFLECTIONS
Explore views overall
o What do they think about the issues discussed today
What stands out
Any hopes, concerns, questions about the Year of Care model
How does this model compare to their current provision
o What else would be helpful in relation to planning their care
©2015 Picker Institute Europe. All Rights Reserved. 16
P2948 | Greenwich CCG LTC YoC final report | AC BH | 040615 | v1.2 Protect
PROMPT: links with other support;
Any other final thoughts?
THANK AND CLOSE