Building the House of Care

January 2014

Martin McShane

Jacquie White

Ed Mitchell

Overview

bull Context

bull Principles

bull Resources

bull Discussion

2

bull Context

bull Principles

bull Resources

bull 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+

Pat

ien

ts (

)

Age band (Years)

Morbidity (number of ETGs) by age band

0

1

2

3

4

5

6

7+

Number ofconditions

BMJ 2009339b2803 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

hellipthe biggest challenge

5

The soft stuffhellipis the hard stuff

6

Mindsets

and beliefs

Values

Individual

behaviours

SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming

your organisationrsquo 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 Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Overview

bull Context

bull Principles

bull Resources

bull Discussion

2

bull Context

bull Principles

bull Resources

bull 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+

Pat

ien

ts (

)

Age band (Years)

Morbidity (number of ETGs) by age band

0

1

2

3

4

5

6

7+

Number ofconditions

BMJ 2009339b2803 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

hellipthe biggest challenge

5

The soft stuffhellipis the hard stuff

6

Mindsets

and beliefs

Values

Individual

behaviours

SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming

your organisationrsquo 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 Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

bull Context

bull Principles

bull Resources

bull 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+

Pat

ien

ts (

)

Age band (Years)

Morbidity (number of ETGs) by age band

0

1

2

3

4

5

6

7+

Number ofconditions

BMJ 2009339b2803 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

hellipthe biggest challenge

5

The soft stuffhellipis the hard stuff

6

Mindsets

and beliefs

Values

Individual

behaviours

SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming

your organisationrsquo 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 Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

BMJ 2009339b2803 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

hellipthe biggest challenge

5

The soft stuffhellipis the hard stuff

6

Mindsets

and beliefs

Values

Individual

behaviours

SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming

your organisationrsquo 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 Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Changing the nature of the conversation

hellipthe biggest challenge

5

The soft stuffhellipis the hard stuff

6

Mindsets

and beliefs

Values

Individual

behaviours

SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming

your organisationrsquo 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 Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

The soft stuffhellipis the hard stuff

6

Mindsets

and beliefs

Values

Individual

behaviours

SOURCE Scott Keller and Colin Price lsquoPerformance and Health An evidence-based approach to transforming

your organisationrsquo 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 Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

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 Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Relationship between number

of long-term conditions and cost

8

LTC Year of Care Programme

Gearing of investment across the system

Public Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Gearing of investment across the system

Public Health

Social Care

(HampWB Board)

Primary Care pound200

CommMH pound500

Specialised pound300

Acute pound1000

pound2000head 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 A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

NHS Expo Seminar Domain 2

Gearing in activity into acute care

10

11

GP Specialist

1990

Specialist

2014

CARE GAP A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

11

GP Specialist

1990

Specialist

2014

CARE GAP A

c

t

i

v

i

t

y

Complexity

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Qu

ality

of

life

pound1 pound10 pound100 pound1000

ICU

ACUTE CARE

0

COMMUNITY CARE

Self-management

Long Term Condition

Management incl Cancer

Third sector

provision

Primary Care

100

Consultant-led

services

Specialist teams Specialty Clinic

Planned procedures

INTEGRATED CARE

Locality teams

SHIFT LEFT

pound5000

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

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

LTC Year of Care Programme

Impact of coordinated care

Person centred

coordinated care

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Person centred

coordinated care

ldquoMy 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 outcomesrdquo

Communication

Information

Decision-making Care planning

Transitions

My

goalsoutcomes

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

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 amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Engaged

informed

individuals amp

carers

Commissioning

Organisational

amp clinical processes

Person-

centred

coordinated

care

Health amp care

professionals

committed to

partnership

working

Plan

Study

Do

Act

The House of Care

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

ndashInformational continuity

ndashManagement continuity

ndashRelational continuity

17

The House supports

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

The House of Care in value to peoplepatients

The House supports National Voices lsquoIrsquo statements

My goalsoutcomes eg bull All my needs as a person were

assessed and taken into account

Communication eg bull I always knew who was the

main person in charge of my care

Information eg bull I could see my health and

care records at any time to check what was going on

Decision-making eg bull I was as involved in

discussions and decisions about my care and treatment as I wanted to be Care planning eg

bull I had regular reviews of my care and treatment and of my care plan

Transitions eg bull When I went to a new

service they knew who I was and about my own views preferences and circumstances

Emergencies eg bull 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

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

The House of Care in value to NHS

pound12bn Avoid ambulatory care

sensitive admissions

though eg following

NICE guidelines (1)

pound08bn Reduction of hospital

admissions for common

LTCs through integrated care

esp frailty comorbid (2)

pound08-12bn Reduce use of low value drugs

devices and elective procedures

using commissioning analytics and clinician education (3)

pound02-04bn Empower people in

supportive self-

management (4)

pound1-16bn Shift activity to cost

effective settings

eg pharmacy minor

ailments (5)

cpound55bn Incentivised wellness

programmes in healthy

pop amp early stage LTCs inc

smoking cessation salt darr

exercise uarr(6)

pound04-06bn Avoidance of drug errors

eg through electronic

recordse-prescribing (7)

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

20

Community Care

Primary Care

GenHospitalseral

University Specialist Facilities

Social Care

General Hospital

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

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 lsquomore than

medicinersquo 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

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

CCGs Building the House at the local community level

What

bullWhat are the principles and philosophy behind the care which commissioners wish to provide eg National Voices I statements

bullWhat is the model to use as framework or providing this care (eg the House of Care supporting care planning)

Which

bull Which population of people with LTCs are being addressed (risk stratification approaches GP disease register frailty index etc)

Where when whom

bull Decide the local model of care ie where and when will all the components of the house be delivered for each group of people and by whom

How

bull 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 ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Building the House ndash

The House of Care Toolkit

bull A framework to bring together all the relevant national guidance published

evidence local case studies and information for patients and their carers

bull It includes information on what tools and resources are required to achieve

person-centred coordinated care and how these can be effectively

commissioned

bull 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

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

To Enter the House first chose your level

National Personal 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

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Organisational and Clinical Processes

Person centred-

coordinated care

Health and Care

Professionals

committed to

partnership

working

bull Integration

bull Culture

bull Technology

bull Care Co-ordination bull Care Planning

bull Information and Technology

bull Care Planning

bull Safety and Experience

Informed and

engaged patients

and carers

bull Self Management

bull Information and

Technology

bull Group and Peer

Support

bull Care Planning bull Carers

Commissioning bull Service User and Public Involvement

bull Contracting and Procurement

bull Needs Assessment and Planning

bull Joint commissioning

bull Metrics

bull Evaluation

bull 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

bull Guidelines Evidence and

National Audits

bull 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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

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

ndash Commissioning ndash which is not simply procurement but a system improvement process the outcomes of each cycle informing the next one

ndash Engaged informed individuals and carers ndash enabling individuals to self-manage and know how to access the services they need when and where they need them

ndash Organisational and clinical processes ndash structured around the needs of patients and carers using the best evidence available co-designed with service users where possible

ndash Health and care professionals working in partnership ndash 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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

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 meets

their physical social and emotional wellbeing needs regardless of how many

long-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

bull Focussing on

receptionists

conversations in general

practice

bull Practice Health

Champions

bull 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

bull Information provided to

the patient prior to the

appointment

bull During the appointment

achievable goals should

are set in partnership I

bull Capturing gaps between

preferences and care

received

bull 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

bull Ongoing open dialogue

with the patient andor

their carer about their

choice and experience of

using medicines to

manage their condition

bull Recognising the patientrsquos

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

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Engaged

informed

individuals

and carers

Consultation Preparation

Resources

Right Conversation at the Right Time The Health Foundation

httpwwwrightconversationorg

When doctors and patients talk making sense of the consultation The Health

Foundation

httpwwwrightconversationorgwhendoctorsandpatientstalkpdf

Back to care

planning

Engaged

informed

individuals

and carers

Care Planning Process

Resources

Shared decision making NHS England

httpwwwenglandnhsukourworkpesdm

Tools for shared decision making NHS England

httpwwwenglandnhsukourworkpesdmtools-sdm

Care Planning Royal College of General Practitioners

httpwwwrcgporgukclinical-and-researchclinical-resourcescare-planningaspx

Deciding together Care planning in long term conditions NHS Kidney Care

February 2013

httpwwwcmkcnnhsukattachmentsarticle37Deciding20together2020Care

20planning20in20long20term20conditions[1]pdf

Back to care

planning

Engaged

informed

individuals

and carers

Medicines Optimisation

Resources

Medicines Optimisation Helping patients to make the most of medicines

Good practice guidance for healthcare professionals in England Royal

Pharmaceutical Society

httpwwwrpharmscompromoting-pharmacy-pdfshelping-patients-make-the-

most-of-their-medicinespdf

Good practice in prescribing and managing medicines and devices General

Medical Council

httpwwwgmc-ukorgPrescribing_Guidance__2013__50955425pdf

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

bull Single point of contact

bull Professionals talk to each other

bull Services quick and responsive

people are promoted to stay

independent and active

bull 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

bull Transition following discharge from

hospital

bull Transition related to changes in long

term care needs

bull Transition from childrens to adult

services

Health amp 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 Fund

httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-

improving-outcomes-working-together

Integrated Care and Support Pioneers programme NHS IQ

httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-

careaspx

Integrated Care ndash Better Care Fund ndash Local Government Association

httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-

journal_content56101804096799ARTICLE

Integrated care value case toolkit

httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-

journal_content56101804060433ARTICLE

ICASE - Integrated Care Support and Exchange

httpwwwicaseorgukpgdashboard

Kings Fund Integrated care making it happen

httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen

Back to integration

Health amp 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 Fund

httpwwwkingsfundorgukpublicationsintegrated-care-patients-and-populations-

improving-outcomes-working-together

Integrated Care and Support Pioneers programme NHS IQ

httpwwwnhsiqnhsukimprovement-programmeslong-term-conditionsintegrated-

careaspx

Integrated Care ndash Better Care Fund ndash Local Government Association

httpwwwlocalgovukwebguesthealth-wellbeing-and-adult-social-care-

journal_content56101804096799ARTICLE

Integrated care value case toolkit

httpwwwlocalgovukhealth-wellbeing-and-adult-social-care-

journal_content56101804060433ARTICLE

ICASE - Integrated Care Support and Exchange

httpwwwicaseorgukpgdashboard

Kings Fund Integrated care making it happen

httpwwwkingsfundorgukprojectsintegrated-care-making-it-happen

Back to integration

Health amp care

professionals

committed to

partnership

working

Care Transition

Resources

Lost in transition Moving young people between child and adult health

services Royal College of Nursing

httpwwwrcnorguk__dataassetspdf_file0010157879003227_WEBpdf

Transitions between childrenrsquos and adultrsquos health services and the role of

voluntary and community childrenrsquos sector VSS POLICY BREIFING

httpwwwncborgukmedia42225transition_to_adult_services_vss_briefing

pdf

Transition National Council for Palliative Care

httpwwwncpcorguktransitions

Coordinated transition between health and social care NICE

httpwwwniceorgukmedia7C566TranstionBetweenHealthAndSocialCare

DraftScopepdf

Back to integration

Health amp care

professionals

committed to

partnership

working

The House of Care ndash Build your own house What elements need to be in place for YOUR local population

Commissioning

Organisational and clinical processes

Engaged informed individuals amp carers

Health amp care professionals committed to

partnership working

Back to house