Optimum Continence Service Specification. Prof. Hilary Thomas KPMG Healthcare and Life Sciences Strategy Group, UK

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1 Optimum Continence Service Specification Prof. Hilary Thomas KPMG Healthcare and Life Sciences Strategy Group, UK

2 Expert panel members Adrian Wagg (chair) Our expert panel Professor of Healthy Aging, Department of Medicine, University of Alberta Diane Newman Nurse Practitioner, Adjunct Associate Professor of Urology in Surgery; Co-Director, Penn Centre of Continence and Pelvic Health Paul van Houten Care of the Elderly physician; expert in continence care Kai Leichsenring Researcher, European Centre for Social Welfare Policy and Research 2

3 Why is there an urgent need for a continence care service specification? No widely-recognised standard care model Poor levels of access Under-recognition of incontinence Unnecessary preponderance of specialist care Lack of focus on wider care needs Insufficient provision of containment products Low priority of continence care on the policy agenda 3

4 Our project: scope and methodology Purpose To create an evidence-based service specification setting out the ideal organisation of continence care delivery Scope Urinary and faecal incontinence in community-dwelling adults Applicability across different national healthcare systems Methodology Evidence-gathering Synthesis of evidence Validation 4

5 Principles of development for the service specification Optimal use of resources Equity of access and treatment Patient-centred care Upholding professional standards Quality governance Adherence to evidence-based clinical guidelines 5

6 1 Core components of an optimal Case detection Initial assessment and treatment continence service 2 Enabling technologies 3 Case co-ordination 4 Specialist assessment and treatment Communitybased support Containment products 6

7 Key Recommendations 1. Develop robust referral pathways Important to ensure patients receive timely and effective care 2. Use continence nurse specialists for initial assessment and treatment, where available Can manage and treat incontinence more effectively than primary care physicians Where not possible, focus on training existing healthcare professionals 7

8 Key Recommendations 3. Use a case co-ordinator to ensure a patient-centred approach Accompanies service user along care pathway Single point of contact to ensure smooth delivery of care 4. Promote use of self-management tools or techniques Patients & caregivers may prefer active role in treatment decision-making Providing information on managing incontinence can lessen demand 8

9 Key Recommendations 5. Specialists should play a key role in quality governance, training and dissemination of best practice Should have well-defined roles separate to those providing initial assessment and treatment... HOWEVER, hold key insights and knowledge in the areas of quality governance, training and dissemination of best practice 6. Use a comprehensive standardised assessment of user, product, and usage-related factors to assess needs with regards to containment products Use standardised assessment of following factors as per international standard (ISO 15621: 2011):User related factors; Product-related factors; Usage-related factors Needs of each patient must be reassesed periodically 9

10 Key Recommendations 7. Technology should enable self-care, connect patients and caregivers, and enable providers to monitor progress and troubleshoot problems Technology can: Fill gaps where resources and manpower are lacking Connect patients, caregivers and health care professionals Overcome embarrassment and stigma for patients visiting their doctor 8. For payers: in order to provide the highest quality continence care, ensure care standards are incentivised Transparency on outcome indicators can motivate improved performance Financial incentives linked to outcomes can also motivate powerfully Operational performance measures can indicate level of efficiency 10

11 Key Recommendations 9. Establish accredited programmes of training Recommend establishment of certificate in continence care nursing Where a shortage of nurses, set up accredited training programme for other health and social care professionals 11

12 Patient profiles: suggested Stress and urgency Once identified initial assessment and treatment should be undertaken by dedicated nurse-led service Straightforward cases will undergo lifestyle/behavioural interventions More complex or refractory cases to go to specialist Neurological In most cases referral will be activated by neurology specialists or specialist neurology nurses Patients will usually require joint management by the physician or nurse specialist Treatment is usually conservative for both urinary or faecal incontinence but may involve surgery organisation Faecal Once identified initial assessment and treatment should be undertaken by dedicated nurse-led service Patients with red-flag symptoms to be referred to specialist for immediate investigation Case co-ordination important to manage social impact of illness Elderly / cognitive impairment Cases will be mostly detected by primary care physician or specialist elderly care nurse Case co-ordination best undertaken by specialist elderly care nurse/healthcare professional who knows patient with continence nurse specialist to play facilitatory role Usual management strategy will be based on containment but in some cases surgery will be indicated 12

13 Health system variations UK UK continence nurse specialists appear well suited to proposed role but numbers must increase Healthcare professionals (including primary care physicians) require education CQUINS (quality incentive payments) may be useful lever to improve outcomes United States Responsibility for initial assessment and management should move away from specialist physicians Deeply fragmented nature of system means solutions will vary by local health economy Recent health care reforms may provide opportunity to reduce more costly interventions Netherlands Primary care-based nurse practitioners can provide both initial assessment and treatment and case co-ordination Continence nurse specialists based in hospitals to provide care for more challenging patients Longer policy terms would allow payers to hold providers to account on longer-term outcomes India Developing infrastructure currently precludes delivery of comprehensive service Important to work with families and communities and make innovative use of technology to offset lack of resources Large numbers of existing alternative medical practitioners may be able to provide more basic care 13

14 Measuring quality and service performance Focus on outcomes E.g. symptom relief; clinical safety; QoL improvement; appropriate use of containment products; patient experience Recommend regular systematic clinical audits How to use outcome indicators Tool to improve transparency primarily Can link to payments to incentivise improvement Performance measures E.g. Proportion of at-risk patients screened; ratio of patients per trained staff member; number of patients seen & treated; waiting times; total costs per patient; proportion of appropriate referrals for specialist investigations 14

15 Implementation considerations Training and education of current healthcare professionals Workforce planning Continence care promotion Patient and caregiver involvement Payer involvement Working across health and social care boundaries Procurement of containment products Data collection 15

16 9. Establish accredited programmes of training 1 Case detection Initial assessment and treatment 2. Use continence nurse specialists for initial assessment and treatment, where available 1. Develop robust referral pathways 2 Enabling technologies Communitybased support 7. Technology should enable self-care, connect patients and caregivers, and enable providers to monitor progress and troubleshoot problems 4. Promote use of self-management tools or techniques 3 Case co-ordination Containment products 4 5. Specialists should play a key role in quality governance, training and dissemination of best practice Specialist assessment and treatment 3. Use a case co-ordinator to ensure a patient-centred approach 6. Use a comprehensive standardised assessment of user, product, and usagerelated factors to assess needs with regards to containment products 8. For payers: In order to provide the highest quality continence care, ensure care standards are incentivised 16

17 9. Establish accredited programmes of training 1 Case detection Initial assessment and treatment 2. Use continence nurse specialists for initial assessment and treatment, where available 1. Develop robust referral pathways 2 Enabling technologies Communitybased support 7. Technology should enable self-care, connect patients and caregivers, and enable providers to monitor progress and troubleshoot problems 4. Promote use of self-management tools or techniques 3 Case co-ordination Containment products 4 5. Specialists should play a key role in quality governance, training and dissemination of best practice Specialist assessment and treatment 3. Use a case co-ordinator to ensure a patient-centred approach 6. Use a comprehensive standardised assessment of user, product, and usagerelated factors to assess needs with regards to containment products 8. For payers: In order to provide the highest quality continence care, ensure care standards are incentivised 17

18 Closing remarks There is no single configuration of services that will work in all cases Important to provide all of the core components of an ideal service More cohesive, integrated healthcare systems could make the difference Continence care promotion will be vital to the success of services We now have an optimum continence care service specifcation to help you improve continence care wherever you are! 18

19 Prof. Hilary Thomas KPMG Healthcare and Life Sciences Strategy Group, UK Hilary.Thomas@kpmg.co.uk

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