House of Care Making the space for a better

conversation for people with long term conditions

Sue Roberts Chair, Year of Care Partnerships‘Talking – differently health coaching for behaviour change and patient centred care’ Event East of England: November 11th 2014’

Setting the sceneWho’s here? Wave if……

• You work with someone on tasks / solutions (short periods)

• You work with people with LTCs in routine planned care• You manage staff• You help ensure the environment is right• You plan training • You work in the community / outpatients • You work in general practice • You work in acute settings

Health Coaching - talking differently

Mindsets

Skills

The context / environment ?

The House of Care

Making space for the conversation

Health Coaching and planned care for people with long term conditions

Making it easier to do the right thing

Guardian, 4th Jan 2014

The Challenge!

15 million people Making it personal for

everyone!

The individual's perspective

Making better use of NHS contact time……..Care and support planning

More meaningful conversations about•Support for self management to live good lives•Disease surveillance•Care provision•Linking and coordinating with social care and community activities

Agreed & shared ‘care plan’

Information gathering

Goal setting and action planning

Information sharing

Care Planning in the beginning

Person’s story Professional story

Year of Care

Preparation Results/agenda setting prompts sent to patient > 1 week before

consultation;

Care Planning “ a meeting of equals and experts”

Prepared HCP and patient meet to review how things are going

consider what's importantshare ideas

discuss options and develop a Care plan

Informationsharing

Consultation and joint

decision making

Agreed andshared goals and actions (care plan)

1st visit

Between visits

2nd visit

Disease Surveillance Health Care Assistant performs

‘annual review’ tests

Informationgathering

National VoicesCare and support planning

http://www.nationalvoices.org.uk/principles-care-support-planning

I got more information out of it than …..previously. …

they were probably giving us the information,(but) they

were giving it us in a different way. [PWD12]

Being prepared

… Absolutely 100% better ……for me and for the patients.[GP}

Year of Care

‘Its actually more rewarding. We spend more time engaging with patients....rather than ticking boxes’ (Nurse practitioner)

I am more in control. I have the …information so I am not so reliant on the system. I can share the information with my own family and use it to encourage them to be more healthy. (Bengali Patient TH)

Engaged, inform

ed ‘patient’

HCP com

mitt

ed to partnership w

orking

Organisational processes

Commissioning- The foundation

Consultation skills / attitudes

Integrated, multi-disciplinary team

and expertise

Senior buy-in and local

champions

Prepared for consultation

Information / education

Emotional and psychological

support

Test results / agenda setting prompts: beforehand

Contact numbers and safety netting

IT: clinical record of care planning Know your population

Year of Care

Commission care planning

Quality assure and monitor

Establish /publicise menu of community

support

House Of Care

• A home for care planning

• Flexible ‘plan’ for local tailoring

• Check list

• Metaphor

Engaged,

informed patient

HC

P com

mitted to

partnership working

Organisational processes

Commissioning- The foundation

Collaborativecare

planning consultation

Send test results/ agenda setting

prompts

Consultation skills / attitudes

Prepared for consultation

Procured time for consultations, training, & IT

Addressing attitudes, skills and infrastructure

Benefits

• Improves patient experience • Reported changes in behaviour • Suitable across diverse populations • Clinical outcomes across a number of care

planning cycles• Improves job satisfaction• Improves team work• Cost neutral at practice level• Better links with specialists

International Evidence Base

Reproducible intervention

>4000 practitioners and 60 quality assured trainers Year of Care Training and Support Team

A generic approach

Beyond diabetes...

Diabetes care plan

COPD care plan

Arthritis care plan

Depression care plan

Your care plan

Holmside Medical Group•One care planning conversation,

including all conditions → one care plan

•Achieved for all 30% on QOF registers

‘It’s what we do now – we would never go back’

Elderly, multi morbidity, frailty

……I'm listened to…….you may not have all the

answers…….you’ve helped me work

things out

If you would like to find out more

www.yearofcare.co.ukenquiries@yearofcare.co.uk

‘Surveying your House of Care’

www.yearofcare.co.uk

Engaged,

informed patient

HC

P com

mitted to

partnership working

Organisational processes

Collaborativecare

planning consultation

Surveying your House

• Going well?• What needs to be embedded?• Not so well/missing ?• What could you change?• What might you need help with?

Engaged,

informed patient

HC

P com

mitted to

partnership working

Organisational processes

Commissioning- The foundation

Involving people in their care

Engaged,

informed patient

HC

P com

mitted to

partnership working

Organisational processes

Commissioning- The foundation

Involving people in their care

Send test results/ agenda setting

prompts

Know your Population

Consultation skills / attitudes

Senior buy-in & local champions to support & role

model

Integrated, multi-disciplinary team & expertise

Information/Structured education

‘Prepared’ for consultation

Emotional & psychological

support

Quality assure and measure

Procured time for consultations, training, & IT

Identify and fulfil needs

IT: clinical record of care planning

If you would like to find out more

www.yearofcare.co.ukenquiries@yearofcare.co.uk

Holmside in NewcastleA whole team approach

9000, inner city, two sites

• Practice initiated• YOC: Care and support planning training• Facilitated ‘time in’– getting the whole practice on board• Redesigned the systems – admin/HCA key• Continuous in house training – building generic skills• Implemented a four step approach

– Information gathering (+/- sharing) separate from– Care planning consultation

Achieved for all 30% on QOF registers

‘It’s what we do now – we would never go back’

What needs to be in place to ensure that ?

People with LTCs are prepared for

their care planning consultations / better

conversations , are involved in decision

making and are supported to self

manage ?

Health Care Professionals are prepared for a care planning

consultation / better conversations and work in partnership with people

with long term conditions?

Prepared ‘person’

Prepared professional

Identification of Individual

Care and Support Planning

Conversation

Elderly, multi morbidity, frailty

……I'm listened to…….you may not have all the

answers…….you’ve helped me work

things out

Engaged,

informed patient

HC

P com

mitted to

partnership working

Organisational processes

Commissioning- The foundation

Collaborativecare

planning consultation

Send test results/ agenda setting

prompts

Know your Population

Consultation skills / attitudes

Senior buy-in & local champions to support & role

model

Integrated, multi-disciplinary team & expertise

Information/Structured education

‘Prepared’ for consultation

Emotional & psychological

support

Quality assure and measure

Procured time for consultations, training, & IT

Identify and fulfil needs

IT: clinical record of care planning

Surveying your House

• Going well?• What needs to be embedded?• Not so well/missing ?• How would you know if it was working?• How much clinical engagement is there for

working differently?