11 November 2014

Our Approach in Community Services

Sara Hill, Podiatry Business Manager/Clinical LeadJo Wallis, Senior Community PhysiotherapistJo Hood, Podiatry Service Development Lead

Debbie Beales, Lead Nurse Coronary Heart Disease ServiceJo Reid, Physiotherapy Team Leader

What patients want from talking with their clinicians

Angela Coulter Senior Research Scientist

Nuffield Department of Population Health, University of Oxford

I N F O R M AT I O N , I N VO LV E M E N T , S U P P O RT

What Patients Want

Angela CoulterHealth Coaching conference

Lynford Hall, November 2014

Person centred coordinated care

“I can plan my care with people who work together to understand me and my

carer(s), allow me control, and bring together services

to achieve the outcomes important to me.”

Information

My goals/outcomes

Communication Decision making

Care planning

Transitions

Managing Long Term Conditions

Professional care – 5 hours per year

Self-care – 8,755 hours per year

Diabetes Web of Care

Alzheimer’s Web of Care

Were you involved as much as you wanted to be in decisions about your care and treatment?

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

10

20

30

40

50

60

70

80

90

100

54 54 53 53 52 51 52 52 52 52 55 56

%

% responding ‘Yes, definitely’

Source: NHS inpatient surveys

Care and Support Planning

Personalised care planning aims to ensure that individuals’ values and concerns shape the way in which they are supported to live with and self-manage their long-term condition(s)

Engaged,

informed patients

HC

Ps com

mitted to

partnership working

Organisationalprocesses

Responsive commissioning

Personalised care

planning

Coulter, Roberts, Dixon: Delivering better services for people with long-term conditions – building the House of Care, King’s Fund, October 2013

What Patients Need to Know

• What are my options?• What are the benefits and

possible harms?• How likely are these benefits

and harms?• What are your goals, do they

match mine?• What can I do to help myself?• What can you do to support

me?

Sharing Expertise

Clinician

• Diagnosis• Disease aetiology• Prognosis• Management options• Outcome probabilities

Patient

• Experience of illness• Social circumstances• Attitude to risk• Values and

preferences• Goals

One-time Decisions for Tests or Treatments

Chronic Care Management Decisions

Personal Care Planning

Shared Decision Making

Care Planning Consultation

Patient’s agenda Professional’s agenda

Goal setting and action planning

Information sharing

Agreed and shared care plan

Information gathering

Information sharing

14

1. Preparation

2. Goal setting

3. Action planning

4. Documentin

g

5. Coordinating

6. Suppor

ting

7. Review

ing

Care planning

cycle

TEAMcare, USA

Aim: • To improve outcomes for patients with major depression and poorly controlled diabetes, coronary heart disease or both by developing a patient-centred, primary care-based, care management intervention for multiple conditions

TEAMcare Tools

• Collaborative goal-setting and action planning

• Evidence-based pharmacotherapy• Structured consultations and monitoring every 2-3 weeks with physician or nurse

• Proactive nurse follow-ups to support self-care using motivational interviewing, problem-solving techniques and maintenance plans

• Staff training and weekly supervision

TEAMcare – Results

Improvements in:• HbA1c• Cholesterol• Blood pressure• Depression• Quality of life• Confidence to self-manage• Cost-effectivenessKaton 2010, von Korff 2011, Lin 2012, Katon 2012, Ludman 2013

Systematic Review of Personalised Care Planning

• 10,000 abstracts scanned• 43 articles included describing 19 unique studies (RCTs)

• USA (13 trials), Australia (1), China (1), Denmark (1), Netherlands (1), Taiwan (1), UK (1)

Participants and Settings

• 10,856 participants• Diabetes (12 trials), mental health (3), heart failure (1), end-stage renal disease (1), asthma (1), various conditions (1)

• Primary/community clinics (17)• Hospital clinics (3)

Interventions

• Aims – behaviour change among patients (19)• Behaviour change among patients AND clinicians (4)

• Goal setting, action planning, follow-up (19)• Tools – information packages, structured consultations (coaching), peer support, group visits

• Clinicians – nurses/therapists (14), doctors (6), peer coaches (2), mental health providers (2)

Outcomes

• Physical health• Psychological health• Subjective health status• Self-management capabilities• Health-related behaviours• Resource use• Adverse effects

Outcomes

• Physical health: blood glucose control

• Psychological health: depression• Subjective health status: mixed• Self-management capabilities: self-efficacy

• Health-related behaviours: mixed• Resource use: mixed• Adverse effects: none

Care Planning Works Best When it is ………

• Comprehensive (all 7 stages of care planning cycle)

• Higher intensity (longer duration (> 3 months), more contacts)

• Integrated with usual care• Well supported (training, supervision and support for clinicians as well as patients)

What We Have Learnt

Traditional practice styles…….

• Create dependency• Discourage self-care• Ignore preferences• Undermine confidence• Do not encourage

healthy behaviours• Lead to fragmented

care

Informed, Empowered Patients Have the knowledge, skills and

confidence to manage their own health and healthcare,

And they……• Make healthy lifestyle choices• Make informed and personally

relevant decisions about their treatment and care

• Adhere to treatment regimes • Experience fewer adverse events• Use less costly healthcare

Health Affairs Feb 2013

The Greatest Untapped Resource