1. Pouring IT On Gareth Paterson - Regional Manager LTCC

2. http://dilbert.com/strips/comic/2010-05-08/ Summary How does the aim of SCIMP relate to the Long-term Conditions Agenda? Workstreams and the use of information in LTC care? The integration of plug and play. Analysing information pathways. Audience Participation

3. Introduction SCIMP’s principal objectives include promoting, assisting and developing the processes to enable the safe and effective sharing of clinical information across NHS Scotland organisations. LTCC helps local staff to deliver improvements in patient centred services and change the way care is provided for people with long term conditions across three workstreams Complex care, Self Management and Care Pathways.

4. Correct systems in place to capture data Agreed minimum dataset and key indicators Measurement of impact Identify local trajectories Use Better Together programme to capture qualitative indicators Identification of critical success factors PDSA Statistical process control, Digital stories, “Talking Points” Story Boards, Process Outcomes, Change Outcomes Project Focus

5. “a proactive approach focused on high-risk patients with a combination of medical, nursing, pharmaceutical care and social care needs” Implementing care management is a complex and far reaching development that will involve changes to the way we deliver care and how we share and manage information flows. Complex Care Case Management Identification of Risk Information Flow

6. Kaiser Permanente

7. Person centred care. Adopting an enablement approach. Proactive care that is multidisciplinary. Integrated working. An anticipatory approach to assessment, care planning and review. Coordination of care. Clarity about responsibility and accountability. Communication with patient, carer, care team and all agencies. Patient reviews that are carried out systematically on a multidisciplinary and multi-agency basis. Collaborative working. Condition Pathways

8. Self Management Making the Connections – Food For Thought “Effective self management relies on the provision of accurate, relevant, timely and accessible information from a trusted source on a basis which people feel is sensitive to their situation.”

10. Services from e-systems Person Centred Safe Effective To Achieve all these things it is necessary to analyse the flow of information to understand why we need it and how the information adds to the quality of the service we provide.

11. In what ways do ‘Quick Wins’ need to be supported within the system? What process changes are needed to integrate new systems? What ways can the manual be modified? Can we use present available hardware in a different way to augment new systems? Email? Video conferencing? Phone conferencing?

12. What are we trying to accomplish? “ A bad system allows a good person to behave badly while a good system makes a bad person behave well.” With the adoption of new systems we may be in danger of abandoning active data collection for passive supply systems.

13. The challenges of successful Information Flow Like any flow information can be diverted redirected, misdirected and dammed. Passive Flow = “Delayed Care” Passive planning = “Reactive Care”

14. Date of Birth ----------------- AGE ----------------- Under 40/40-65/Over 65 ----------------- OLD/YOUNG Information Identity

15. AGEO/YOver 65AGE Information Chain Analysis Information Stream

16. Transmission Large Databases Inconvenient Access Waiting Over- processed Over- production Incorrect Information 7 Brakes on information flow

17. Analysis of Constraints What is necessary for the development of ‘Information Pull’? Where does information get hung-up?

18. Primary Care Secondary Care Acute Care Social Care Third Sector Community Care

19. Pouring IT on What is the impact of IT on those individuals with Long-term conditions? 1. Proactive information gathering and process development offers faster integration of new systems in the organisation. 2. Maintaining a proactive information gathering mentality reduces brakes on flow and increases responsiveness. 3. By proactively sourcing information required for medical processes, procedures and treatments clinicians can have more confidence in the information. 4. Establishment of procedures reduces unnecessary variation.

20. Examples of Enhanced Information Flows? EPCS. ECS. EKIS. SPARRA ACP Personal Passport Clinical Portal Multidisciplinary Forum Digital Stories Estimated Date of Discharge

21. Anticipatory Care A “thinking ahead” philosophy of care. Working with people and those close to them to set and achieve common goals. Anticipatory care planning is applied to support those living with a long term condition to plan for an expected change in health or social status. To allow this information that already exists needs to be made available by another individual.

22. Audience Participation

23. Work Shop Identify one line of information flow that you know is not as fluid as it could be? In the group consider what part of the information is valuable and why? Consider the examples of waste that you know of. Write down three ways in which one of these flows could be changed to reduce the impact of this waste within the information flow?

24. Output 1. Identify what information is required 1. Identify the pathway 1. FLOW 1. Active vs Passive Flow.

25. Questions?