Title: Patient Centred Care for Vulnerable Older People in the Community Nurse Consultants Meeting July 07 Presenter: Clare Abley, Nurse Consultant Vulnerable Older Adults, PhD Student Newcastle University

Outline  Background and aims of study  Methods  Emerging findings / themes  Focus on similarities and differences between constructions of professionals and older people.  Next steps

Background  ‘Older people should receive patient centred care…, they should be treated as individuals, make informed choices about their care and receive timely and coordinated services’ (DH, 2001).  Literature on person centred care, but  Most relates to nursing homes or hospital settings, or to people with dementia  No studies focus on the overall provision of health and social care for vulnerable older people living in the community  None apply a social constructionist paradigm

Aims  To explore the social construction of patient centred care for vulnerable older people in Primary Care  To identify factors which promote and barriers to the provision of patient centred care for vulnerable older people in the community

Methods  Constructivist approach  Theoretical (purposive) sampling  Unstructured focus groups - topic guide, older people, health and social care professionals, volunteers – recorded and transcribed (some interviews)  Constant comparative analysis  Memos on methodology, codes, coding frame, emerging themes / ideas.  Use of NVIVO (CAQDAS)  Individual meetings with key stakeholders (older people) to discuss emerging themes

Emerging findings: Setting the Scene  ‘I’d like to think that all the work we do is person centred really. I think that’s the aim…… the person as the focus of the work we do and …. we work in partnership with people.’

Similarities and Differences between Professionals’ and Older People’s Constructions – Individual LevelProfessionals Respect for older person Partnership PC relationship PC decision making PC communication Building rapport Listening Being sensitive to older person’s feelings PC assessment PC goals and goal setting Allowing risk taking and selective rule breaking Spending time with patients Older People Staff attributes Approach taken by staff Time to sit and listen Being treated as a person Supportive Helpful Patient centred assessment Outcomes Functional Psychological wellbeing Older person ‘really’ able to talk to staff Making one feel good about oneself Services provided

Partnership  ‘You try, you know, to impose a non judgmental approach, you try not to impose your values on the situation at all, but I think however hard you try part of you does come out in the work. I mean it’s working with that as well, and working with issues of power and control. You might aim for a partnership but ultimately when you know people view you as a person with help in that situation, families do, the people you work with, and it’s trying to balance it out and sort of eliminate that gap and work to be on an equal basis……we work to come decisions together, not ‘this is what I think you should do.’

Spending time with patients  ‘I think the time that we spend with people helps us become more patient centred …… from the outset when we do our initial screening we spend a definite period of time and it can be half an hour to an hour and a half in some cases. And there’s talking to someone, going through the issues and that helps …… identify the issues …… and again building up that relationship, that rapport, things do come to the fore and I think that helps with being more sort of client focused, patient centred.’

Staff Attributes  Very nice / pleasant people  Friendly  Skilled  Expert knowledge  ‘There was a lady came, very, very nice mind.....and er the girl, the young lady left me her phone number if I ever needed it again to get in touch with her, which I was very, very appreciative, very nice persons they were and really helpful.’  ‘ Well she was certainly clever because she put the chair together, I mean she definitely knew all the bits and pieces of the chair. Mind they’re all nice, these girls are lovely girls, friendly, do anything and er cosy you know and they’re really very good.’

Approach taken by staff ‘How could that be more patient centred, how could that be more focused on you as a person? ‘Um to be treated as though I am a person because I always say you’ve got to be well to be ill, because somebody’s who’s perhaps a bit you know doesn’t know what’s going on with dementia or anything, I think they just rule all over you actually, and I think more discussion.’

Similarities and Differences between Professionals’ and Older People’s Constructions – Individual LevelProfessionals Respect for older person Partnership PC relationship PC decision making PC communication Building rapport Listening Being sensitive to older person’s feelings PC assessment PC goals and goal setting Allowing risk taking and selective rule breaking Spending time with patients Older People Staff attributes Approach taken by staff Time to sit and listen to you Being treated as a person Supportive Patient centred assessment Outcomes Functional Psychological wellbeing Older person really able to talk to staff Making one feel good about oneself Services provided

Service LevelProfessionals Team workTeam work Managing the caseManaging the case PC systems or processesPC systems or processes Allocation of specific GPAllocation of specific GP Holistic approachHolistic approach Multidisciplinary inputMultidisciplinary input Older People General health check up Gender specific services Follow up Accessibility Continuity Comprehensiveness Care at home

Using patient centred systems or processes (professionals)  E.g. allocation of complex patients (multiple needs) to a named GP  ‘The more problematic patients we’ve assigned to specific GPs so that the same patient is seeing the same doctor all of the time, and then it means that if we do have problems we can go straight to one person who knows that patient and knows their history, instead of going to whoever happens to be on call that day…… and it means we can pin a couple of GPs down, one to lead and one to be buddy of the lead GPs …….to be completely up-to-date and au fait with what’s going on with those patients. It works really, really well, it means the patients get a very responsive kind of treatment don’t they.’

Service LevelProfessionals Team workTeam work Managing the caseManaging the case PC systems or processesPC systems or processes Allocation of specific GPAllocation of specific GP Holistic approachHolistic approach Multidisciplinary inputMultidisciplinary input Older People General health check up Gender specific services Follow up Accessibility Continuity Comprehensiveness Care at home

Next Steps  Further consideration of :  Factors affecting patient centred care (barriers and facilitators)  Patient centred care specifically for vulnerable older people  Alternatives to patient centred care  Further analysis of data relating to vulnerability

 Any questions? Contact details:

Patient centred decision making  Appears to include:  Older person making decision with support from staff  Staff making decision based on ‘patient centred evidence’  Possible continuum  Ambiguities i.e. implication that onus on staff to make final decision (move into a care home), followed by inference that older person would make final decision, suggests staff are unsure as to who actually makes the final decision in some cases  Perhaps less important who makes the final decision, key point being that either the patient’s views or some other ‘pc evidence’ is taken into consideration

Characteristic of Patient Centred Care Related to Outcomes  Functional outcomes  ‘Back to normal’  Intervention results in independence  Help to achieve independence in ADL  Emotional or psychological wellbeing  Older person able to ‘really talk’ to staff  Enjoying the attention  Making one feel good about oneself  Services provided  Services that meet needs  Patient centred care package