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The House of Care: Engaged, informed individuals & carers

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Presentation on theme: "The House of Care: Engaged, informed individuals & carers"— Presentation transcript:

1 The House of Care: Engaged, informed individuals & carers Commissioning Organisational & clinical processes Person-centred, coordinated care Health & care professionals committed to partnership working Plan Study Do Act The House of Care describes four key interdependent components that, if implemented together, will achieve patient centred, coordinated service for people living with long term conditions and their carers.

2 Building the House – The House of Care Toolkit
A framework to bring together all the relevant national guidance, published evidence, local case studies and information for patients and their carers. It includes information on what tools and resources are required to achieve person-centred coordinated care and how these can be effectively commissioned. 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.

3 To Enter the House first chose your level:
Personal Local National Supporting for professionals, services users and carers to work together to understand, plan and deliver person centred coordinated care. Examples of local examples of good practice that will inform the commissioning of services at a local level . National and international guidance, evidence, tools and resources that will enable the construction of the House of Care at the next two levels.

4 Organisational and Clinical Processes
Click on the links below for more information about each component and use this to build your own house Organisational and Clinical Processes Build my own house Guidelines, evidence and national audits Care Delivery Information and technology Care Planning Safety and Experience Person centred- coordinated care Informed and engaged patients and carers Health and Care Professionals committed to partnership working Self management Information and Technology Group and peer support Care Planning Carers Integration Culture Workforce Technology Care Co-ordination Care Planning Commissioning Needs Assessment and Planning Joint commissioning of services Metrics and Evaluation Service User and Public Involvement Contracting and procurement Care Planning Tools and levers

5 Person centred- coordinated care
Back to house 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 Commissioning – which is not simply procurement but a system improvement process, the outcomes of each cycle informing the next one. Engaged, informed individuals and carers – enabling individuals to self-manage and know how to access the services they need when and where they need them. Organisational and clinical processes – structured around the needs of patients and carers using the best evidence available, co-designed with service users where possible. Health and care professionals working in partnership – listening, supporting, and collaborating for continuity of care.

6 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 Health & care professionals committed to partnership working 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 Single point of contact Multi disciplinary team working Professionals talk to each other Services quick and responsive people are promoted to stay independent and active 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 Transition following discharge from hospital Transition related to changes in long term care needs Transition from children's to adult services.

7 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 Integrated Care and Support Pioneers programme, NHS IQ Integrated Care – Better Care Fund – Local Government Association Integrated care value case toolkit ICASE - Integrated Care Support and Exchange Kings Fund Integrated care: making it happen Health & care professionals committed to partnership working Back to integration

8 Health & 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 Transitions between children’s and adult’s health services, and the role of voluntary and community children’s sector, VSS POLICY BREIFING Transition, National Council for Palliative Care Coordinated transition between health and social care, NICE Health & care professionals committed to partnership working Back to integration

9 Culture Health & care professionals committed to partnership working
To promote an environment where people with long term conditions, their carers and professionals involved in their care have an equal relationship and a joint responsibility for managing their care. To ensure parity of esteem where physical health is valued equally with mental health. Health & care professionals committed to partnership working Back to house Promoting a partnership approach to care To better involve patients in decisions about their own health to facilitate self-care. Key Components Developing equal relationships between patients and professionals Sharing information to support patients to self-care Clinical Champions and Professional Support Effective leadership from professional bodies us key to embedding the type of culture change that is needed. Key Components Supporting the workforce to adjust to a new way of working Governance Professional practice Cultural relationships. Parity of Esteem People with poor physical health are at higher risk of experiencing mental health problems and people with poor mental health are more likely to have poor physical health. Key Components Valuing mental health and physical health equally. Considering the physical impact of living with a mental health condition and the mental health impact of living with a long term condition

10 Promoting a partnership approach to care
Resources Shared decision making, NHS England Measuring Shared Decision Making A review of research evidence, NHS Right Care Changing the culture: resources developed by AQuA, NHS England Health & care professionals committed to partnership working Back to culture

11 Clinical champions and professional support
Health & care professionals committed to partnership working Resources Care Planning, Royal College of General Practitioners 6 C’s Compassion in Practice, NHS England Association for Directors of Adult Social Services Royal College of Nursing https://www.rcn.org.uk/ Back to culture

12 Health & care professionals committed to partnership working
Parity of Esteem Health & care professionals committed to partnership working Resources Valuing mental health equally with physical health or “Parity of Esteem”, NHS England Long-term conditions and mental health The cost of co-morbidities, The Kings Fund Mental Health Partnerships Back to culture

13 Workforce Health & care professionals committed to partnership working
Ensuring that the workforce is configured to support partnership working both between different professional groups and between services users and professionals providing care. This will include considerations regarding integration of the workforce to provide a coordinated approach to people living with long term conditions and clarification of roles and responsibilities of professionals and opportunities for training. Health & care professionals committed to partnership working Back to house Integration The long term conditions workforce should offer a seamless pathway of care to patients and carers. Effective workforce integration should be in place to achieve this. Key Components Joint training Skill mix Joint health and social care roles Communication Multi-disciplinary team working Roles, responsibilities and training Ensuring the workforce supporting people living with long term conditions are aware of the role they play and are appropriately trained. Key Components Continuing professional development Person specifications Training

14 Health & care professionals committed to partnership working
Integration 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 Integrated Care – Better Care Fund – Local Government Association Coordinated transition between health and social care, NICE Integrated Care and Support: Our Shared Commitment https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198748/DEFINITIVE_FINAL_VERSION_Integrated_Care_and_Support_-_Our_Shared_Commitment_ pdf Health & care professionals committed to partnership working Back to workforce

15 Roles, responsibilities and training
Resources Long Term Conditions, Skills for Health Delivering better services for people with long-term conditions Building the house of care, Kings Fund Health & care professionals committed to partnership working Back to workforce

16 Information and Technology
Information systems and technology that facilitate equal relationships between people with long term conditions, their carers and professionals providing their care. This may be achieved through better access to information or technology to allow patients to have a greater role in condition management. Health & care professionals committed to partnership working Back to house Shared information systems Facilitating the sharing of information between different professional groups involved in the care of an individual to improve the management of care. Sharing information will aim to ensure the wider need for the individual are considered by all professionals involved in their care. Key Components Joint care plans Shared access or joint information systems across health organisations and between health and social care Patient Held Record The patient is given a copy of the record to keep, and to take to health appointments, to help manage healthcare tasks and communication. PHRs are formal and structured records that are given to patients to enable the continuity and quality of care. Key Components Structured sections of patient and healthcare information Blank sections to enable patient note-taking and healthcare staff notes

17 Shared Information Systems
Resources Technical Approaches for Sharing Care Plans, NHS QIPP Workstream Summary Care Record, Health and Social Care Information Centre Health & care professionals committed to partnership working Back to information and technology

18 Health & care professionals committed to partnership working
Patient Held Record Resources Summary Care Records, NHS Choices Enabling patients to access electronic health records Guidance for health professionals, Royal College of General Practitioners Patient record access: turning it on, sharing the learning, The Health Foundation Health & care professionals committed to partnership working Back to information and technology

19 Health & care professionals committed to partnership working
Co-ordination of care Supporting people to better understand the health and social care system so that they can get the support they require when they need it. This can range from a person having a named professional as a first point of contact with the health system to a case manager responsible for coordinating the health and social care for people with multiple complex long term conditions. Health & care professionals committed to partnership working Back to house Case Management A targeted, community-based and pro-active approach to care that involves case-finding, assessment, care planning, and care co-ordination accurate case-finding to ensure patients with highly complex and multiple conditions receive high-intensity professional support. Key Components: Processes to identify those suitable for case management are in place Case managers have an appropriate case load Case managers are able to effectively coordinate care Care Co-ordination Supporting individuals find their way around the, sometimes complex services provided by health and social care. Key Components Care navigators Directory of services Identifying and assessing needs for people living with long term conditions and their carers Ability to identify the most appropriate services for the individual Developing support plans

20 Health & care professionals committed to partnership working
Case Management Resources Case Management, What it is and how it can best be implemented, The Kings Fund Case management and community matrons for long term conditions, British Medical Journal Health & care professionals committed to partnership working Back to co-ordination of care

21 Health & care professionals committed to partnership working
Care Co-ordination Resources Safer passage: how care navigators help improve mental health services, Health Services Journal Co-ordinated care for people with complex chronic conditions, Kings Fund Care co-ordination through integrated health and social care teams, Kings Fund Health & care professionals committed to partnership working Back to co-ordination of care

22 Health & care professionals committed to partnership working
Care Planning Professionals need to recognise that the personal assets that patients (and their families) bring to the care planning process are as important as the clinical information in the medical record. They must ensure contacts people with long term conditions, their carers and have meet their physical, social and emotional wellbeing needs and best support them to manage their condition. Effective care planning requires both patients and professionals to adequately prepared in advance and are clear about the purpose of the care planning process. Health & care professionals committed to partnership working Back to house Care Planning An interactive partnership between clinician and patient supporting self management . Key Components Information should be given to the patient prior to the appointment During the appointment achievable goals should be set in partnership. Ongoing process Capturing gaps between preferences and care received and feeding back these preferences to inform future planning. Motivational support Facilitating healthy, sustainable behaviour change by supporting people living with long term conditions to take a more active role in their own care. To do this, people require skilled support and motivation from their clinicians. Key Components Motivational interviewing techniques Health coaching Using a guiding style to engage with patients Clarify strengths and aspirations, evoke their own motivations for change, and promote autonomy of decision making.

23 Health & care professionals committed to partnership working
Care planning Resources Shared decision making, NHS England Tools for shared decision making, NHS England Care Planning, Royal College of General Practitioners Embedding SDM in NHS care: Resources developed by Capita, NHS England Health & care professionals committed to partnership working Back to care planning

24 Health & care professionals committed to partnership working
Motivational Support Resources Motivational Interviewing in Primary Care, Tim Anstiss Motivational interviewing 1: background, principles and application in healthcare, The Nursing Times Health Coaching, NHS Direct Co-creating Health, Health Foundation Health & care professionals committed to partnership working Back to care planning

25 Organisational and Clinical Processes Care Planning
The organisation of health and social care services practices should be structured to support the care planning process. The process involves 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. Back to house Care Planning Structure Services should to be configured to support the ongoing collaborative care planning process. Key Components Allowing time for multiple long term conditions to be considered where required Allowing information on clinical test results to be provided to the patient and the professional prior to the care planning discussion Considering the frequency of appointments and reviews to provide an opportunities to review short and longer term goals and have mechanisms in place for patient recall Recording Outputs of Care Planning Consultations Processes are in place that allow information captured in care planning appointments to be recorded to inform future care planning consultations and future service provision. Key Components Information systems to records agreed goals Access to menus of available services to support individuals to achieve their goals Information systems to record gaps between individual preferences and services provided to inform commissioning

26 Organisational and Clinical Processes Care Planning Structure
Resources Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care, NHS Diabetes https://www.diabetes.org.uk/Documents/nhs-diabetes/care-planning/partners-in-care-implementing-care-planning-approach.pdf Care Planning Improving the Lives of People with Long Term Conditions, Royal College of General Practitioners Back to care planning

27 Organisational and Clinical Processes
Recording Outputs of Care Planning Consultations Resources Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care, NHS Diabetes https://www.diabetes.org.uk/Documents/nhs-diabetes/care-planning/partners-in-care-implementing-care-planning-approach.pdf Back to care planning

28 Organisational and Clinical Processes
Safety and Experience People with long term conditions should receive high quality care that is safe and reliable and that also delivers excellent patient experience. Processes should be in place to ensure patient experience is captured and to allow safety concerns to be identified and risks for future incidents to be reduced. Back to house Safety Promoting an active safety management approach to identify potential risk while helping to improve monitoring and measuring of safety indicators. Key Components Evidence based procedures in place promoting safety Potential safety concerns identified and addressed Processes for identifying adverse incidents and near misses Safety concerns are freely raised and openly discussed Safe processes to optimise the use of medicines Experience Ensuring processes are in place so that the experience of the service users can be recorded and reviewed so that services delivered reflect the needs and preferences of people living with long term conditions and their carers. Key components Mechanisms are in place to capture the experiences of people living with long term conditions and their families and carers These experiences inform future planning and delivery of services

29 Organisational and Clinical Processes
Safety Resources Patient Safety, NHS England European Union Network for Patient Safety and Quality of Care Patient Safety Resource Centre, The Health Foundation Patient Safety, Practical information, tools and support to improve patient safety in the NHS Medicines Optimisation: Helping patients to make the most of medicines Good practice guidance for healthcare professionals in England, Royal Pharmaceutical Society. Good practice in prescribing and managing medicines and devices, General Medical Council Back to safety and experience

30 Organisational and Clinical Processes
Experience Resources Improving Patient Experience, NHS England 6 C’s Compassion in Practice, NHS England Transforming Patient Experience, NHS Institute Patient Experience, Kings Fund Back to safety and experience

31 Organisational and Clinical Processes Information and Technology
Information and technology is a key factor underpinning successful organisational and clinical processes to support people living with long term conditions and their carers. Two Important elements of this are how information and technology can be used to identify which Individuals in a population will most benefit from care and to share information about these individuals both within and between organisations. Back to house Risk Stratification Using relationships in historic population data to estimate the future use of health care services for each member of a population. Key Components Use of information from primary and secondary care services in addition to social care data Useful both for population planning purposes and for identifying which patients should be offered targeted, preventive support. Information systems Professionals are required to have timely and relevant access to information in order to effectively manage people living with long term conditions. Key Components Information sharing and access of records across organisational boundaries Integrated information systems is key to ensuring the care is delivered around the needs of the individual as a whole.

32 Organisational and Clinical Processes
Risk Stratification Resources Risk Stratification, NHS England Predicting and reducing re-admission to hospital, The Kings Fund RISKPROFILING AND CARE MANAGEMENT SCHEME, NHS England Risk Prediction Network, NHS networks Information Governance and Risk Stratification: Advice and Options for CCGs and GPs Advice on Risk Prediction and Stratification, London: National Information Governance Board for Health and Social Care, July 2012 Back to information and technology

33 Organisational and Clinical Processes
Information Systems Resources Better information means better care, NHS England Keeping your online health and social care records safe and secure, NHS England PatientGuidanceBooklet.pdf New technology can improve the health services delivered to millions of people, NHS England Back to information and technology

34 Organisational and Clinical Processes
Guidelines, Evidence and National Audits Ensuring the services delivered to provide person centred care for people living with long term conditions follow the appropriate guidelines and based on robust evidence where this is available. Back to house Guidelines To help professionals deliver the best possible care offering the best value for money. Key Components Independent, authoritative and evidence-based information Effective ways to prevent, diagnose and treat disease and ill health, reducing inequalities and variation. Specific diseases as well as generic principles for care. National Audits Audits allow health organisations to compare their performance against specific standards and national trends, enabling them to deliver better care for their patients. Key Components Usually conducted in disease specific areas such as COPD, Kidney Disease or Stroke. Evidence Based Practice The use of robust evidence to inform the commissioning and delivery of services in practice. Where evidence is not available this may involve working with academic institutions to contribute to the body of evidence available. Key Components Routine use of evidence in service planning and delivery

35 Organisational and Clinical Processes
Guidelines Resources National Institute of Clinical Excellence Social Care Institute for Excellence Map of Medicine End of Life Care Quality Standard, Public Health England British National Formulary Back to guidelines and national audits

36 Organisational and Clinical Processes
National Audits Resources Clinical audits, Health and Social Care Information Centre Audit and Quality Improvement, British Thoracic Society https://www.brit-thoracic.org.uk/audit-and-quality-improvement/ Audits, University College London GRASP Audit Tools, PRIMIS Back to guidelines and national audits

37 Organisational and Clinical Processes Evidence Based Practice
Resources NICE Evidence Search Health and Social Care, NICE The Cochrane Library Social Care Institute for Excellence Shared Learning Implementing Evidence Based Practice, NICE Back to guidelines and national audits

38 Organisational and Clinical Processes
Care Delivery How services and processes are configured to up to promote a person centred approach to care as people with long term conditions move through the health and social care system. This will include how to ensure care is being provided in the most clinically appropriate place whilst paying regard to quality of life and efficiency. Back to house Workforce Ensuring workforce processes support professionals to deliver person centred co-ordinated care for people living with long term conditions. Key Components Training of medical, nursing allied health professionals and social care workforce Consideration of the skill mix of the workforce Care Closer to Home Ensuring processes are in place to allow people living with long term conditions to be cared for in a community setting where this is clinically appropriate. Key Components Access to specialist clinics in the community Pathways to prevent admission and to facilitate earlier discharge from hospital. Rehabilitation Following condition exacerbations rehabilitation may be required to promote recovery and prevent further exacerbations. Key Components Generic rehabilitation programmes such as social care support to return home safely Condition specific e.g. stroke or pulmonary rehabilitation.

39 Organisational and Clinical Processes
Workforce Resources Long Term Conditions, Skills for Health Improving services for people with long-term conditions through large-scale workforce change, NHS Employers Long term conditions e-learning tools for NHS and social care workforce, Department of Health https://www.gov.uk/government/news/long-term-conditions-e-learning-tools-for-nhs-and-social-care-workforce Back to care delivery

40 Organisational and Clinical Processes
Care closer to home Resources Avoiding hospital admissions Lessons from evidence and experience, The Kings Fund Interventions to reduce unplanned hospital admissions: a series of systematic reviews, Purdy S. et al (June 2012) Avoiding hospital admissions What does the research say? The Kings Fund Back to care delivery

41 Organisational and Clinical Processes
Rehabilitation Resources Pulmonary Rehabilitation, National Institute of Clinical Excellence Stroke Rehabilitation, National Institute of Clinical Excellence Improving Patient Outcomes through restructuring Recovery, Rehabilitation and Re-ablement, Department of Health Back to care delivery

42 Engaged, informed individuals and carers
Self management Empowering people with the confidence and information to look after themselves when they can, and visit the GP when they need to, giving people greater control of their own health and encourages healthy behaviours that help prevent ill health in the long-term. Back to house Personal budgets Personal health budgets are money in lieu of NHS and social care services. They can be spent on a range of care and support, including things which are not traditionally commissioned. They are a tool for commissioning services at the level of the individual. Key Components Assessment of goals for the personal health budget Agreed care plan between the NHS and the individual Lifestyle Promoting healthy lifestyle choices for people living with long term conditions to ensure they experience a good quality of life and to reduce their likelihood of developing further conditions and to reduce their impact on health and social care service. Key Components Every contact counts Targeted smoking cessation services Weight management services Exercise programmes Activation Activation is a measure of an individual’s knowledge, skill, and confidence for self-management. Higher levels of activation have been associated with reduced healthcare utilisation and positive changes in self management behaviour. Key Components Assessment of the activation levels Tailoring support levels of activation Mechanisms to increase activation levels

43 Engaged, informed individuals and carers Back to self management
Personal Budgets Resources Personal health budgets, NHS England Building on a people’s movement for change, People Hub Personal Health Budgets Evaluation https://www.phbe.org.uk/ Personal Health Budgets Toolkit, NHS England Direct payments and personal budgets for social care - Commons Library Standard Note Back to self management

44 Engaged, informed individuals and carers Back to self management
Lifestyle Resources Making Every Contact Count, NHS Yorkshire and Humber The NHS’ role in the public’s health, NHS Future Forum https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216423/dh_ pdf Enabling People to Live Well, The Health Foundation Self Care Forum Back to self management

45 Engaged, informed individuals and carers Back to self management
Activation Resources Changing the culture: resources developed by AQuA, NHS England Summary of the Evidence on Performance of the Patient Activation Measure (PAM), NHS Kidney Care Back to self management

46 Information and Technology
Engaged, informed individuals and carers Information and Technology Information and technology is a key factor to supporting people living with long term conditions and their carers to feel engaged with and informed about their care. Professionals should ensure information provided is tailored to meet the needs of the individual. Technology such has telehealth or mobile apps can be used to give individuals independence and allow them to play a greater role in managing their care. Technology can also be used to give people alternative ways of accessing information, education and services. Back to house Information Personalised packages of information designed to help people with long-term conditions to feel more informed and more in control of their health and wellbeing. Key Components Information on conditions, treatments, services and support available. Provision of a personalised information resource based on an assessment of the individual’s information needs. Telehealth and telecare Telecare and telehealth services use technology to help people live more independently at home. They include personal alarms and health-monitoring devices Key Components Assessment of who will benefit most from telehealth/telecare Joint assessment and referral process Service structures to underpin telehealth and telecare Digital health In addition to telehealth and telecare there are other forms of technology that can support people living with long term conditions and there carers. Key Components Mobile apps Video or internet based consultations Online forums Social networking and text contacts Online education resources

47 Engaged, informed individuals and carers
Digital Health Resources NHS Choices Health Apps Library, NHS Choices Long Term Condition Management, Airedale Digital Healthcare Centre Back to technology

48 Engaged, informed individuals and carers Telehealth and Telecare
Resources Telecare and telehealth technology, NHS Choices Telehealth and telecare, The Kings Fund 3 million lives The impact of telehealth and telecare: the Whole System Demonstrator project, Nuffield Trust Back to technology

49 Engaged, informed individuals and carers
Information Resources Information Prescription Service, NHS Choices NHS Choices Information prescriptions - an e learning tool, NHS Employers Getting the most out of information prescriptions, Macmillan Social prescribing for mental health – a guide to commissioning and delivery, Care Services Improvement Partnership – North West Back to technology

50 Group and Peer support Engaged, informed individuals and carers
Patients, carers and volunteer members of the public can offer opportunities to support people living with long term conditions. This support can be offered in the community, through groups set up specifically for this purpose or on an individual level. Peer support is often effective as the people providing the support often have first hand experience of living with a long term condition or caring for someone who does. In addition to the educational impact of courses, many patients value the social support gained from meeting other people who are living with a long-term condition. Back to house Peer support groups Peer-led support groups are proven to help people manage long-term conditions by reducing depression, building self-esteem and improving physical and mental health. Key Components Awareness of peer-support programmes that are available Peer-support groups are considered in the care planning process Lay educator programmes A Lay Educator is someone who delivers group education to people with a long term condition alongside a professional. A Lay Educators may have a long term condition, have a family member with a long term condition Key Components Identification of individuals willing to be lay educators Development of programmes that are suitable for delivery by lay educators Community health champions People who, with training and support, voluntarily bring their ability to relate to people and their own life experience to transform health and well-being in their communities Key Components Champions become involved in community groups/events and offer informal support people to join in healthy activities

51 Engaged, informed individuals and carers
Peer Support Groups Resources Developing Peer Support for Long Term Conditions, The Mental Health Foundation The Power of Peer Support, The Health Foundation Back to peer support

52 Engaged, informed individuals and carers Lay Educator Programmes
Resources Lay Educator Study, The DESMOND project Lay educators in asthma self management: Reflections on their training and experiences, Clare Brown a, Jean Hennings b, A.-L. Caress b, M.R. Partridge (2007) Back to peer support

53 Engaged, informed individuals and carers Community Health Champions
Resources Community Health Champions, Altogether better Community health champions: creating new relationships with patients and communities, NHS Confederation Changing multiple health behaviours: the contribution of health trainers and community health champions, The Kings Fund Back to peer support

54 Engaged, informed individuals and carers Consultation preparation
Care Planning People living with long term conditions and their carers working in partnership with professionals, identifying priorities, discussing care and support options, agreeing goals they can achieve themselves. Co-producing a single care plan, that meets their physical, social and emotional wellbeing needs regardless of how many long-term conditions they have. Back to house Consultation preparation Research by the Health Foundation has identified elements that can make a consultation between patient and healthcare professional more successful. Key Components Receptionist conversations in general practice Practice Health Champions Appointment guides 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 Information provided to the patient prior to the appointment During the appointment achievable goals should are set in partnership. Capturing gaps between preferences and care received Feeding back preferences to inform future planning.

55 Engaged, informed individuals and carers
Care Planning Process Resources Shared decision making, NHS England Tools for shared decision making, NHS England Care Planning, Royal College of General Practitioners Deciding together Care planning in long term conditions, NHS Kidney Care , February 2013 Back to care planning

56 Engaged, informed individuals and carers Consultation Preparation
Resources Right Conversation at the Right Time, The Health Foundation When doctors and patients talk: making sense of the consultation, The Health Foundation Back to care planning

57 Carers Engaged, informed individuals and carers
There are around 6.5 million people who report that they are carers in the UK (Carers UK, Census Analysis 2012). It is important that the health and wellbeing of carers is considered so that they feel supported to continue to care for people living with long term conditions. Back to house Health and wellbeing of carers Being a carer can have an impact on an individual’s health and wellbeing. The physical and mental health needs of carers should be considered in addition the wider impact on their quality of life. One key area for consideration is financial pressure for carers which can come from reduced earnings and increased outgoings related to the costs of ill health or disability. Key Components Identification of the carer population and challenges they might be facing Assessment and mechanisms to improve the health and wellbeing status of carers Advice and signposting to services that can support with financial and employment pressures Carer support and respite Access to services which allow carers to continue working, maintain their health and well-being, keep families together and ensure that carers have a life of their own and are able and willing to continue caring Key Components Consultation to understand carer support needs Services offering support and respite depending on the level of need of the individual carer

58 Engaged, informed individuals and carers
Health and Wellbeing of Carers Resources Carers UK Looking After You, Carers UK Carers’ Wellbeing, NHS Choices Caring & Family Finances Inquiry , Carers UK Your Work and Career, Carers UK Back to carers

59 Engaged, informed individuals and carers Carer support and respite
Resources Carers UK Practical Help, Carers UK Evidence-based planning and delivery of local support for carers, Carers UK Carers and the NHS practice briefing , Carers UK Back to carers

60 Metrics and Evaluation Metric and Outcome Development
Information to inform commissioning processes and development of metric and outcomes that allow services to be evaluated effectively to ensure meeting the needs of the local population. Back to house Information Commissioners have a number of key intelligence requirements that need to be addressed to deliver great commissioning.  Key Components Accurate, relevant and timely information that enables commissioners to design and plan cost effective services that will improve the quality of life for people living with long term conditions and their carers. Metric and Outcome Development Meaningful indicators are set so performance management metrics reflect the proposed outcomes of the service whilst being mindful of the practical implications of measurement. Key Components Development should consider nationally set outcomes as well as outcomes set locally. Consideration of how metrics can be collected in practice SMART (Specific Measurable, Attainable, Realistic, Timely) measures are used Evaluation Evaluation should consider the impact the service has on its users in addition to the wider impact on the health and social care economy as a whole. It should consider the economic and activity impacts in addition to service user experience and health and social care outcomes Key Components Evaluation criteria set in service specifications Consider the if the metrics by which services are monitored are appropriate Commissioning

61 Back to metrics and evaly
Information Resources Levels of Ambition Atlas, NHS England Commissioning for Value – a comprehensive data pack to support CCGs, NHS England Data and knowledge gateway - Public Health England Toolkit published to help improve services and close the financial gap in ‘Any town’ , NHS England Better data, informed commissioning, driving improved outcomes: clinical data sets Statistics, NHS England Back to metrics and evaly Commissioning

62 Outcome and metric development
Resources CCG outcomes indicator set Public Health Outcomes Framework https://www.gov.uk/government/collections/public-health-outcomes-framework Measurement Masterclass series for senior clinical leaders How to measure for improving outcomes: a guide for commissioners Back to metrics and evaluation Commissioning

63 Back to metrics and evaluation
Resources Evaluating healthcare quality improvement, The Health Foundation. Quality and Service Improvement Tools for the NHS, NHS IQ Approaches to Economic Evaluation in Social Care, SCIE Social Return on Investment Back to metrics and evaluation Commissioning

64 Needs Assessment and Strategic Planning Reducing Inequalities
Assessment of need for people living with long term conditions and their carers across a whole health economy, considering all health and social care needs to inform future commissioning. Accurate, timely and relevant information for both health and social care is required to ensure to inform this process. The outcomes of the health needs assessment process will inform strategic planning decisions about which services should be commissioned to best meet the needs of the local population. Back to house Needs Assessment The process by which the need for services and other interventions are fully assessed. It is a vital analysis which underpins any strategic plan. Key Components Epidemiological –information about the area of interest and potential interventions. Comparative –comparing existing services with established standards or with other populations. Corporate – capturing the views of stakeholders. Strategic Planning Planning across a local health and social care economy, setting priorities about what should be commissioned to deliver the best possible outcomes for people living with long term conditions. Key Components Joint priority setting Determining which services and pathways will be the most appropriate to meet local need. Reducing Inequalities The numbers of people living with long term conditions and the corresponding impact they have on health and social care is not distributed evenly across a population. Tackling health inequalities is a key consideration for commissioning services for people living with long term conditions Key Components Identifying those at greater risk of developing long term conditions Identifying those who may needs extra support to manage their condition(s). Commissioning

65 Back to Needs Assessment and Planning
Strategic Planning Resources Strategic and Operational Planning 2014 to 2019, NHS England Wellbeing and health policy https://www.gov.uk/government/publications/wellbeing-and-health-policy Improving the public's health - A resource for local authorities (Dec 2013), The Kings Fund Delivering better services for people with long-term conditions -Building the house of care, The Kings Fund Commissioning High Quality Care for People with Long Term Conditions, The Nuffield Trust Back to Needs Assessment and Planning Commissioning

66 Effective Commissioning
Needs Assessment Resources Modelling tool Clustering of unhealthy behaviours over time Implications for policy and practice Joint Strategic Needs Assessment, NHS Confederation Joint Strategic Needs Assessment, Health and Social Care Information Centre Back to Needs Assessment and Planning Effective Commissioning

67 Reducing Inequalities
Resources Health Inequalities Gap Measurement Tool, Public Health England Health Inequalities Intervention Toolkit, Department of Health Health inequalities: concepts, frameworks and policy, NICE Back to Needs Assessment and Planning Commissioning

68 Joint Commissioning of Services
Health and social care commissioners working together to decide what kinds of services should be provided to local populations, who should provide them and how they should be paid for to promote integration across health and social care. Considering long term conditions commissioning across the whole pathway of care ensuring services are commissioned and provided according to the needs of the individual reducing barriers imposed by organisational boundaries. Back to house Commissioning Responsibilities Knowledge of the statutory obligations of the different organisations involved in commissioning services. Organisations working together to ensure joint accountability of outcomes across the whole system Key Components Understanding “who is responsible for what” to allow integrated pathways to be created and commissioned effectively. Integrated pathway and service development Colleagues across health and social care working in partnership to commission integrated pathways of care meet the needs of the individual Key Components Commissioning pathways that allow how health and social care professionals to work closely together to offer seamless pathways of care Commissioning of services that patients and carers feel are well coordinated. Shared Funding Shared funding can facilitate joint commissioning supporting health and social care commissioners to work closely together to decide together how to allocate resources to deliver the best outcomes across the health and social care economy. Key Components Mechanisms for sharing or pooling resources Mechanisms for deciding how joint resources will be allocated Back to house Commissioning

69 Back to joint commissioning of services
Shared Funding Resources Integrated Care – Better Care Fund – Local Government Association Better Care Fund Planning – NHS England Making best use of the Better Care Fund Spending to save? (Jan 2014) Year of Care, NHS Improving Quality Back to joint commissioning of services Commissioning

70 Commissioning Responsibilities
Resources A framework for collaborative commissioning between clinical commissioning groups Commissioning fact sheet for clinical commissioning groups Public health commissioning in the NHS 2014 to 2015 https://www.gov.uk/government/publications/public-health-commissioning-in-the-nhs-2014-to-2015 Working together to deliver the Mandate Strengthening partnerships between the NHS and the voluntary sector Who Pays? Determining responsibility for payments to providers, August 2013, NHS England Back to joint commissioning of services Commissioning

71 Integrated Pathway and Service Development
Resources Winterbourne View Joint Improvement Programme, Local Government Association Integrated care for patients and populations: Improving outcomes by working together - A report to the Department of Health and the NHS Future Forum, Kings Fund Integrated Care – Better Care Fund, Local Government Association Integrated working for better outcomes, Social Care Institute for Excellence Back to joint commissioning of services Commissioning

72 Service User and Public Involvement
Ensuring that the people likely to receive services and their carers are involved in the planning and commissioning of services. This might be through patient and public Involvement at a population level or with service users and carers at an individual level. Back to house Involvement in planning Service user involvement is one of the most important measures and determinants of quality in health and social care planning and delivery By involving services users and members of the public commissioning should result in high-quality services that more adequately reflect user need. Key Components Routine involvement of service users and carers in service planning Service User Experience Ensuring that their views of service users and carers are captured so that services commissioned reflect the needs and preferences of people living with long term conditions and their carers. Key components Mechanisms are in place to capture the experiences of people living with long term conditions and their families and carers These experiences inform future commissioning of services Commissioning

73 Involvement in planning
Resources Transforming Participation in Health and Care, Guidance for Commissioners, NHS England Invest In Engagement, Picker Institute Europe Community commissioning case studies https://www.gov.uk/government/publications/community-commissioning-case-studies Patient involvement , National Voices People Powered Health, Nesta Involving and consulting carers - a good practice guide, Carers UK Back to Service and Public User Involvement Commissioning

74 Service User Experience
Resources Patient involvement , National Voices Experience Based Design, NHS IQ Involving and consulting carers - a good practice guide, Carers UK Improving Patient Experience, NHS England Transforming Patient Experience, NHS Institute Patient Experience, Kings Fund Back to Service and Public User Involvement Commissioning

75 Contracting and Procurement Service Specifications
Developing the levers and incentives to enable professionals to deliver person centred coordinated care for people living with long term conditions. Managing the process of tendering for the supply of goods and services and awarding contracts. Agree process by which new service/pathway will be contracted for Back to house Contracting Models To ensure contracting models are the most appropriate for the service commissioned. To consider models that can be commissioned jointly across health and social care. Key Components Statutory procurement processes Standard contract models Joint contracting models Reorientation Ongoing evaluation process of commissioned services ensuring the services provided continue to meet the needs of changing populations. Where services are no longer evaluated as effective this may involve decommissioning services and commissioning new services that better meet the needs of the population. Key Components Regular evaluation of existing services Processes for decommissioning services that maintain continuity and minimise disruption Service Specifications Documentation which sets out the necessary requirements of a commissioned service. These documents are key to the contracting process as they not only describe what form the service should take but also how success will be measured and how performance management will take place. Key Components Service specifications The use of service specifications to develop meaningful performance and quality indicators Commissioning

76 Back to contracting and procurement
Contracting Models Resources 2014/15 Standard Contract, NHS England The NHS Standard Contract: a guide for clinical commissioners, NHS England Making savings from contract management, Local Government Association Back to contracting and procurement Commissioning

77 Back to contracting and procurement
Reorientation Resources Guidance for commissioners on ensuring the continuity of health care services, Monitor P3M Resource Centre, Delivering the benefits of change, NHS Connecting for Health Back to contracting and procurement Commissioning

78 Service Specifications
Resources Commissioning toolkit for respiratory services, Department of Health https://www.gov.uk/government/publications/commissioning-toolkit-for-respiratory-services Support for Commissioning Dementia Care, NICE Back to contracting and procurement Commissioning

79 Care Planning Commissioning Commissioning to support care planning
Care planning aims to make best use of health care and local authority services through capturing the needs and preferences of people living with long term conditions and their carers and ensuring this information is fed into commissioning processes. In order for this to happen commissioners for long term conditions services need to consider how services can be configured to best support the collaborative care planning process. Back to house Commissioning to support care planning Commissioners for long term conditions services need to consider how services can be configured to best support the collaborative care planning process. Key Components Commissioning supporting care planning appointment structures in primary care Directory of Services Commissioning to support the information needs of the care planning process Care planning to support commissioning Ensuring that outputs from the care planning process are fed into the commissioning process. Key Components Recording gaps between individual requirements and services commissioned Commissioning mechanisms to capture and transfer care planning information Directory of services Using care planning information to routinely inform the commissioning process. Personal Budgets Personal budgets are essentially a tool for commissioning services at the level of the individual. Personal health budgets are money in lieu of NHS or social care funded services which is spent as detailed in an agreed care plan. Key Components Providing people living with long term conditions with the option of a personal health or social care budget Directory of Services Commissioning

80 Commissioning to Support Care Planning
Resources How information supports personalised care planning and self care, Department of Health https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215952/dh_ pdf At a glance 45: Social care and clinical commissioning for people with long-term conditions, SCIE Delivering better services for people with long-term conditions, Building the house of care . Kings Fund What is a directory of services? Connecting for Health Back to care planning Commissioning

81 Care Planning to Support Commissioning
Resources Long Term Conditions (LTC) Electronic Templates Supporting Personalised Care Planning, NHS Networks Care Planning, Diabetes UK What is a directory of services? Connecting for Health Back to care planning Commissioning

82 Personal Budgets Commissioning Resources
Personal health budgets, NHS England Building on a people’s movement for change, People Hub Personal Health Budgets Evaluation https://phbe.org.uk/ Back to care planning Commissioning

83 Tariff and Funding Models
Tools and Levers The use of tools and levers to allow for effective commissioning processes to achieve the best outcomes for the health and social care economy. This can include the use of different tariff models to fund health and social care support to those with complex needs and commissioning of direct and local enhanced services. Back to house Enhanced Services Enhanced services are those which are commissioned outside of the core primary care contract. They are commissioned where additional need is identified. Enhanced services can be developed locally and nationally to support people living wit h long term conditions. Key Components Evaluation current services and identifying gaps in need that could be met through the commissioning of an enhanced service Direct enhanced services (national level) Local enhanced services (local level) Tariff and Funding Models Whole population tariff models are not always the most effective methods for funding care for people living with complex long term conditions. Alternative tariff or funding models can be considered based on the health and social care needs of and individual rather than based on disease. These models consider an annual risk adjusted capitation budget which is based on these levels of need. Key Components Local changes to tariff to support people with complex needs Risk stratification and identification of those with complex care needs Year of Care Funding Model Commissioning

84 Back to tools and levers
Enhanced Services Resources Enhanced Services Commissioning Factsheet, NHS England Enhanced Services, NHS Employers Back to tools and levers Commissioning

85 Tariff and Funding Models
Resources Year of Care, NHS Improving Quality Confirmation of the 2014/15 National Tariff, NHS England Back to tools and levers Commissioning

86 The House of Care – Build your own house
What elements need to be in place for YOUR local population? Organisational and clinical processes Engaged, informed individuals & carers Health & care professionals committed to partnership working Commissioning Back to house


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