multidisciplinary anticipatory care planning: model to support integration
TRANSCRIPT
Multidisciplinary Anticipatory Care
Planning: A model to support Integration
South Ayrshire Health and Social Care PartnershipKathleen McGuire
Strategic Lead LTC & TEC
BackgroundLocal Planning re Integration: Getting it Right for Mrs MacAnticipatory Care Planning in the context of Outcomes and PolicyPrevious Studies-Nairn & AberdeenshirePolicy• National Clinical Strategy, • TQA for GMS• HSCP Integration & Planning process
Understanding the current state and patterns of collaboration
Getting it right for Mrs MacWho is Mrs Mac?
Mrs Mac is a fictitious women in her 80s with a range of long-term health and social care problems for which she needs care and support.
She lives in Ayr in her own household.
Mrs Mac encounters daily difficulties and frustrations in navigating the health and social care system. Problems include her many separate assessments, having to repeat her story to many people, delays in care due to the poor transmission of information, and bewilderment at the sheer complexity of the system.
Talk to each other and try to join up your
care
Don’t ask me the same questions numerous
times
Try to think of me as a whole person living with different
conditions
Listen to what I want and give me
respect
Try to involve me and others in
preventative and anticipatory work so
care is not just reactive
Have someone who is the main point of contact or ‘co-ordinator’
of my care
Don’t make assumptions
Give me information about all the services and
care that might be available
Include me in all decisions
about me
Improve and simplify your
communication with me
Help me to use
technology where it might be
appropriate
MRS MAC
Approach to this ModelWe hear what you say- what matters• People• Relationships• Culture• Processes
Good enough plansDistributed leadershipDefining collaboration and building a common language
Approach to this ModelOverall objectives clear and realisticResources are adequate to the taskOrganisational DevelopmentStaff were given ownership of the developmentManagement and redesign accountability clearMonitoring and evaluation framework built into
the initiative
Pre RedesignSeparate processes and systems for assessment, care
planning and interventionsCommunication challenges between teamsNo definition of multi-disciplinary teamsDifferent understanding of roles & co-ordination of careChallenges in jointly identifying patients with complex,
multiple or special needsSeparate training and development approachesSeparate IT & Accommodation
Regular meetings with defined MDTPre-selected patients and work upDiscussion around• What can be done to improve care at present• What can be put in place in the event of anticipated
crisis Explore issues, find solutions and agree joint action
plans Collaborate and co-ordinate care focused on personal
outcomes for patients
Staff aspirations
First stepsEstablished MDT• GPs• DNs• ICES• Social Worker• CW and Telehealth • Long term conditions team• CPNs• Acute sector• Pharmacist• Patients/ relatives/ carers
Identify timetable of dates/times for MDT Members/attendance at each MDT meeting Identify patients to select Involve patient, family and carers Joint assessment Commence ACP Consider co-ordinator/lead case manager Consider Evidence Based Intervention Document in ACP Sharing the ACP Regular review and referral
Second Step -ACP Process
Ensure all patients •Consent and can participate•Involved in developing the ACP•Develop a Self management Plan, where appropriate•Are assessed by MDT and have clear triggers and reassessment
timescales•Have ACP shared with Out of Hours, Acute, and other members of
MDT. Patients will also have ACP available in their own home if they so choose
Refer and receive back appropriate patients from Community Ward, Telehealth, ICES and other acute services.
Third step-
Fourth Step – The Tools
“You can’t improve what you don’t measure”
to directly relate activities with the expected outcomes
to demonstrate the impact of activities to assess the "if-then" (causal) relationships
between the elements of the program
Fifth Step – Evaluation &Logic Model Approach
Inputs Activities Outputs Outcomes (impact)
Resources Invested in programme
Activities undertaken
What is produced through those activities
The changes or benefits that result
e.g funding, staff, time
e.g training, education
e.g number of staff trained
e.g increased skills/knowledge
Logic Model
MDT ACP numbers – EMiS report run centrally – practices to apply read codes using template provided
MDT Meetings register – practices to record details of meetings and participants as well as numbers identified/reviewed for ACP
MDT ACP Quality – practices to audit small cohort of ACPs (before, 3mths, 1yr) using audit tool provided
Patient Story– MDTs to produce a case study using template provided, prior to future workshops
Staff experience– Baseline about current working, then again once MDTs established and running a few months
Patient experience – cohort of patients with MDT ACP to be invited to participate in a focus group to give feedback
What, How, When, Who
General Practices and teams have signed up to work in this way
Teams are getting to know each other Communication improved Improved Skill mix and learning between the teams Staff satisfaction Sharing of information and consent to share Quality of Care Plans improved Better co-ordination of care and follow up for patients Improved knowledge of local services and sign posting Improvements in whole systems communication and
collaboration Patient satisfaction and Improved outcomes
Where are we now/Early Impacts
