This will activate and empower people to become more confident to manage their own health.

Transcription

1 Mid Nottinghamshire Self Care Strategy

2 Forward The Mid Nottinghamshire Self Care Strategy will be the vehicle which underpins our vision to deliver an increased understanding of and knowledge about Self Care support and services for patients and carers. This will activate and empower people to become more confident to manage their own health. The strategy connects with numerous local organisations and can only be delivered effectively by partnership working. It requires systematic change and a consistent approach so that it is incorporated across care pathways, from first contact and throughout. The strategy recognises and incorporates the developments in this field within Newark and Sherwood CCG and aims to build on the progress already achieved across Mid Notts. Each CCG will agree local implementation plans to allow for development of patient activation and local culture change. Self care is one of the key priority work streams of the Better Together programme driven by the Department of Health definition of self care: The actions that people take for themselves, their children and their families to stay fit and maintain good physical and mental health; meet social and psychological needs; prevent illness or accidents; care for minor ailments and long term conditions; and maintain health and well-being after an acute illness or discharge from hospital (Department of Health, 2005) Thus self care is the care provided by people or patients, carers and informal organisations rather than statutory organisations but that does not mean professionals do not have any responsibilities to support it. Education underpins success with particular importance around the conversations between professionals and individuals in care planning. Self care is integral to the PRISM model based on the evidence from implementation in Devon. It is important to include and embrace self care because not only does the investment return better outcomes for our population but also returns improved financial outcomes for the health and social care economy. Self management is part of self care. People with long term conditions manage well when they understand and follow complex medical regimes and adopt necessary changes in lifestyle. This can often require support whether in managing aspects of physical health, aspects of adapting everyday activities and roles as well as dealing with the emotions arising from having a particular condition or number of conditions. Page 1

3 For the majority of people with long term conditions, self management can lead to an improved quality of life, better compliance with treatments and interventions plus more appropriate use of services. Hence self care benefits the individual, the health professionals and the health and social care economy. On average, patients are in contact with a health care professional for 3 hours a year compared with 8757 hours looking after themselves which demonstrates that individuals have a strong influence in managing their own care. There is an abundance of literature indicating that investment in self care will deliver better outcomes. For example, more than a decade ago Derek Wanless 2002 report on the future funding of healthcare services in UK envisaged three different scenarios, each with its own resource implications. The fully engaged scenario in which people took active ownership of their own health, and engaged with health and healthcare services through a dramatically increased use of information and technology, was associated with better health outcomes and a lower increase in costs. Since then the evidence and rationale has strengthened so that the Putting Patients First Business plan (NHSE, 2014) has defined related objectives within that plan. It is important that people are informed and enabled to use services and resources appropriately. Currently some people seek advice for minor ailments that could be treated at home; make GP appointments for minor ailments that could be treated in pharmacy; attend A&E or make 999 calls when telephone advice from NHS 111 or their GP would do. The strategy recognises that communicating the right messages to the public underpins success. Similarly the Pharmacy First scheme delivered by local pharmacies to advise people in treatment of minor ailments encourages self care and self management. A preventative approach from care services should be taking place alongside treatment and service provision at all levels. Patients need to be involved in decisions relating to their health whenever possible. Residents must be supported in caring for themselves and their families and in using services appropriately resulting in taking more responsibility for their health. This strategy will enable people to take greater responsibility for their own health. It has a wide remit and includes working with Public Health colleagues to tackle the common risk factors for main diseases. The strategy will help people to self care for minor ailments, improve appropriate use of health and care services and enable supported self- management for people diagnosed with long term conditions. An integral component of the latter is shared decision making. Page 2

4 Context The Better Together proposal has clearly described in detail the rationale for developing self care support that includes enhancing current systems for care planning. The House of Care Model summarises the structure of self care and care planning developments. The activities and interventions or support needed to achieve building the House of Care can be represented by the diagram on the next page. Page 3

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6 The Year of Care approach which supports personalised care planning was developed by a partnership between RCGP, NHS Improving quality, Diabetes UK and QISMET. It states that a patient needs the following in order to be informed and engaged: An awareness of processes and options Support emotionally and psychologically Access to their own records Goal setting Test results sent prior to consultations Structured education and Information. The Year of Care aims to facilitate more effective use of resources by helping providers to move towards more person centred care. Interface with Mental Health Whilst some Mental Health is out of scope in the Better Together Programme, it is recognised that mental health and physical health are inextricably linked. For example, having a stroke is associated with an increased risk of depression or depression caused by debt can result in weight gain with numerous physical health consequences. The strategy supports better mental health outcomes by designing services to link with mental health services as well as supporting people to achieve optimum overall health. This may require positive joint care planning (including self management planning) across all health services tailored to individual needs and circumstances. Furthermore, self care and self management includes activities in relation to the importance of total wellbeing including mental health wellbeing. If people have a feeling of wellbeing they are more resilient and have a greater ability to self care with consequential more measured use of services. The significance of a feeling of wellbeing should not be underestimated especially as we know that psychological issues have a direct impact on a person s sense of wellbeing commonly affecting sickness and health seeking behaviour. Similarly, the role of pastoral care offers much to both individual and community resilience thus supporting self management. Recent development work The Mid Notts Self Care task and finish group which was set up in June 2014 have taken the proposal forward. The group recognised the value of wider engagement and delivered a workshop to agree what people wanted and needed for supported self care in Mid Notts and hence own the components of the strategy. This built on the extensive engagement already undertaken as well as incorporating the views gathered via the Better Together Champions Network. The outputs of the workshop are captured in a graphical illustration of how people saw the journey to achieving supported self care below. The graphical illustration notes some of the key actions and potential challenges on the road map. Page 5

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8 Key representatives from the task and finish group worked to distil the outputs from the workshop to a plan on a page where the ambition or goal is to achieve fulfilment of the National Voices I statements. There is a clear message that people want to feel supported to help them manage their own care as much as they feel possible. This is captured in My Manifesto. Plan on a Page The plan on a page illustrates that there are five main objectives or drivers to achieve the ambition. Page 7

9 My Manifesto Page 8

10 The strategy aims to achieve the ambition by delivering on the five objectives (primary drivers) in order to facilitate an environment where people can care for themselves appropriately. Each of these primary objectives has several underpinning enablers (or secondary drivers) as illustrated on the plan. The five primary objectives are to have: Effective engagement and communication about self care Comprehensive and good quality care planning where people are participants and own their care plan A range of support available for the whole population from health promotion to support for those at high risk of admission to hospital Good education and learning networks for people and carers that underpins taking responsibility for greater independence An accessible one stop shop (Hub) with clear information on choices for support Underpinning plans to support each objective Page 9

11 Effective Engagement and Communication Secondary Drivers Create a Self-Care advocates network to help me, my carers and my support professionals navigate and learn together. Use simple pictures and diagrams to illustrate what Self-Care is about to help us understand it better. Primary Drivers My engagement and communication I want to be confident those who support me, wherever they may be, are on the same page about Self-Care - what it is, why it is needed and what is available. Use language that means something to me and my carers, avoiding professional jargon. Ensure that hospital care is engaged from the start - they need to understand and support the principles of Self-Care when I am admitted and when I am discharged. Articulate the benefits of Self-Care so that those involved, including me, understand what is possible if they work together effectively. Ensure you are always listening to how Self-Care is working. There should be a constant feedback loop - knowing how we are doing using a range of qualitative and quantitative methods that encourage and support those in and entering Self-Care. Better Together Alignment Notes Align to other parts of the Better Together Communication Programme Page 10

12 You said: We need people to understand what we mean by self care, what is available to support them and how to access support and services. We shall: Communicate clear messages and simple illustrations promoting supported self care and self-management to the public and to the workforce via the Better Together Communications and Engagement Workstream. All key stakeholders will actively communicate with public and professionals Keep people well informed about the changes in self care support and how new systems work together Jointly plan effective communication with the Local Authority in meeting the requirements of the Care Act 2014 Include working collaboratively with our growing numbers of Better Together champions to help in effective two way communication and support public relations Provide information about self care and self management in a number of public places such as supermarkets and places with internet facilities (e.g libraries) Develop easy to understand Frequently Asked Questions (FAQs) to illustrate the benefits to key stakeholders i.e. our public, patients and carers, partner organisations, primary care colleagues and all professionals Monitor how well we are doing as an on going process and these monitoring systems will be consolidated over the next 3 years. It is likely to take a couple of years for systems to truly embed Page 11

13 Develop good care planning Ensure my Self-Care Plan is central to the Integrated Care Plan I want to be able to use my Self-Care Plan to feedback what I think about the services I am receiving. My Self-Care Plan I expect support to be joined up, with no duplication and no cracks to fall down. Ensure Self-Care is embedded as an integral part of all your future development and redesign including the Primary Care Strategy. I want to be able to see and contribute to my own plan. I expect all staff supporting me and people I allow to be able to see my plan, contribute to it and take notice of what it says! Better Together Alignment Notes Align with current Map of Medicine work programme to optimise care planning for effective care. Identify how the links wirth the intentions for an integrated care record for Better Together and in particular progress with PRISM. Ensure Self-Care is part of the Primary Care Strategy. Page 12

14 You said: We need personalised care planning with shared decision making as this is fundamental to good care and helps to empower patients to manage their condition based on their needs and preferences so that they can live well. We shall: Recognise and understand what motivates and de-motivates a person to take a proactive part in their own care and incorporate respect for individual wishes into care planning. Support the big culture change that is necessary to achieve this as it requires a significant shift in professional practice as well as individual acceptance of a person centred model of care. Recognise that the culture change requires support through Organisational Development. Develop more streamlined care processes (as part of service redesign) that support best value for service delivery and patient experience. Continue evaluation of The Year of Care training (an evidence based approach to equip staff with new skills in effective care planning) for Integrated Care team members, GP s and practice nurses that has already commenced in Newark and Sherwood CCG. Support Year of Care training across both CCG areas pending evaluation since it has proven quality and financial benefits that could be shared across health and social care. Work with Social care partners to introduce the Year of Care Programme approach to Care planning training in Care Homes and Homecare providers. Support the model to have trained Voluntary Services Assistants who work as part of the Virtual Ward multi-disciplinary teams across the whole of Mid Notts. This is currently delivered by the PRISM Plus model in Newark and Sherwood CCG. It identifies lifestyle and social interventions to support wellbeing, Self Care and better condition management and this fits well to support good care planning. Offer this support to all people, including those residing in care homes, who are identified via the risk stratification process as being at level 2 and above of the Mid Nottinghamshire Long Term Conditions pathway. Link with key Social care colleagues to develop collaborative support planning e.g. in use of personal budgets By establishing trained voluntary workers in each of the 8 Mid Notts Integrated care teams and in the Hub, we will be able to join services up better and offer clear co-produced self care planning that is visible to all appropriate professionals involved whether in acute and urgent care services or community and primary care services. Page 13

15 Range of available support Ensure that there is a simple needs assessment for Self-Care that I can undertand. Define the access criteria and the offer for Self-Care at each level (1-4) in a simple, graphical way that I can understand easily. My Support I want to know that I will be supported and I want to know what to expect and what not to expect in terms of that support. Grow, support and promote Self-Care communities, networks and groups so that they can play a full role in my Self-Care. Provide me with support to help me explore the best way to access and use Personal Care Budgets. Help me use Assistive Technology such as FLO, telehealth and tele-coaching wherever possible and appropriate. Better Together Alignment Notes Using the existing PRISM and PRISM+ to develop and test the Self-Care programme. Page 14

16 You said: The third sector provides an invaluable source of support to communities and are crucial partners but there may be some geographical gaps in provision. We shall: Build on existing partnerships that have strong local networks Support market management and growth in the market to enable new services to be commissioned if needed by building on the outputs from the All Together Healthier event. Undertake a gap analysis of all existing self care / self management support and services available in the community ( including details of access criteria) as it is critical to know where the greatest need is to invest in social capital. Develop a good framework for assessing need for support and access to it. Facilitate people to be well supported in their choices. The trained voluntary worker at the Hub or in the integrated care teams will be well placed to advise, signpost and support people in their choices. Strengthen and coordinate third sector support and befriending schemes so often needed to aid rehabilitation / recovery and prevent loneliness which often has negative consequences. Encourage Peer Support Groups where people, with shared experience or goals, come together to offer each other support and advice. Peer support groups are particularly successful in helping to empower individuals. Inform people about Personal Health Budgets and Personal Budgets which are designed to give more choice and control to individuals over how some money is spent on their care excluding emergency and primary care (GP services). Optimise utilisation of assistive technology both telehealth and telecare - as part of promoting independence. FLO and other assistive technology will be considered during all care planning discussions and patients supported to utilise on line support and telecoaching where appropriate. The benefit of the Nottinghamshire Assistive Technology Team being based at the Ashfield Health and Wellbeing Centre, will give patients easy access to the service which will be seen as an integral part of the Hub. Make full use of virtual platforms to provide information on support available and (with appropriate governance) in provision of tele-coaching, tele-mentoring and internet peer support groups. The design principles of the strategy are in line with the general principles of 7 day services (and where relevant 24 hours a day) and it expects all commissioning of services to meet Equality and Diversity considerations in design of community support and Hub requirements. Page 15

17 Education and learning networks My Education I need to have the confidence to take my first steps in Self-Care. Ensure there are education and coaching packages and learning networks to support self care, so that me, my carers and supporting staff can learn together. I want to know my carers and support staff have the confidence and knowledge to support me in making my choices a reality. Better Together Alignment Notes Align the Self-Care Programme with the Year of Care and Better Together training and development programme Page 16

18 You said: People who are well informed are more confident in managing their condition. Similarly carers and professionals need to be well informed in order to assist in choices and be supported in their caring role. We shall: Include supported self care in workforce training programmes. Clinical teams and staff will be provided with support and training to develop core competences around self-care support Further develop professional learning networks to support well informed professionals in their professional practice Continue to develop structured education programmes such as Expert Patient programmes which offer generic and condition specific education that supports people to self-manage their condition Create the right culture from a young age by including self care information in general education programmes Introduce self care into core modules of professional education in health and social car. Explore the potential with Public Health for an interactive platform on self care education and learning networks offering coaching and mentoring from professionals and peers (including health trainers) to help build knowledge, skills and confidence Enable people to have access to good information. An example is Information prescriptions We shall explore including self care information within the current Information Prescription system with Public Health partners to reduce dependancy on a medical model and strengthen the whole systems approach. This will link with developments on a joint Directory of Services. Page 17

19 Develop the Hub I want a Self-Care Hub as both physical and virtual resources for me, my carers and my support staff - for example, acting as a source of Information Prescriptions. The Self-Care Hub provides me with a single authoritative, current and regularly maintained information directory with signposting to information which is relevant to my needs. It coordinates the different Self-Care information strands of Better Together. My Information I want a simple, clear, current and understandable map of my choices for support and information for Self-Care. If I can understand it then hopefully the staff (whether public sector, 3rd sector or private) who support me will be able to do so as well. The Self-Care Hub is responsible for accreditation of trusted information sources - relevant, current so I have confidence in the information I receive. The Self-Care Hub undertands and develops the best methods and mediums for getting information to me, my carers and my support staff at the right time, in the right place and in the right format. Better Together Alignment Notes Alignment and linkage to Care Navigator Project Alignment to recommissioning project Alignment to Intregrated Care Record/Plan Page 18

20 You said: We want a One Stop Shop for all self care activity that signposts as well as providing and hosting self care support. We shall: Provide a Self care Hub as both a physical base for people to talk to someone face to face or by any other means (phone, internet etc). Arrange for the Self Care Hub to act as a SPA (single point of access) coordinating flexible support that is responsive to the changing local needs in Mid Notts. Require the Hub to forge community health and well being and have the added advantage of co-location with other professionals such as the integrated care teams and intermediate mental health teams as well as third sector personnel. Require the Hub to be a source of information and advice for both public and professionals on what is available to support people and their carers in self management of conditions. Commission the Hub to use a Directory of Services or Directory of Support (DOS) and for the DOS to be compiled and maintained as part of the Hub function. Require that the DOS uses trusted and contemporaneous information rather than just what may be promoted via public websites. Require the DOS to form part of the Care Navigator DOS in order that the clinicians operating the Navigator are aware of immediate support available, facilitate pathway coordination and provide more effective local services. Require the Hub to serve the whole population regardless of healthcare needs as well as taking referrals from professionals. Inform the IMT workstream of the needs of the Hub in order to activate effective DOS management. Require the Hub hours of operation to be in line with other community services (7 day services) as far as possible in order to realise full benefit. Require information to be available in a variety of formats and accessible via different means including virtual platforms. Require the Hub to coordinate structured education programmes and help to identify local gaps in support. Develop a range of Information Management Technology systems to enable people to be able to self-assess their needs, refer to services as appropriate and book appointments, have access to care records and care plans and the Apps for managing long term conditions. In summary, the Hub will enable people to access information and support to better manage their long term condition, to be signposted to self-care options which can help them to make positive life style changes and to learn essential skills. Page 19

21 Commissioning of self care support It is vital that health and social care continue to work together and really consolidate partnerships with the third sector in order to deliver high quality support for people to self care. The Five Year Forward View document highlights that long term conditions take up 70% of health budgets and that many people wish to be more involved in their own care. Changes in how we engage with patients and the voluntary sector as partners will require investment in evidencebased approaches as well as building community resilience. There are obvious mutual benefits in development of joint planning for: communication developing universal information sources (responsive to the Care Act 2014) modelling commissioning of services Impact assessments have been undertaken and will be regularly reviewed to monitor risks, assess quality and support effective implementation. Joint (Health and Social care) funding and commissioning of self care services should be used wherever possible and appropriate in order to meet shared objectives. Any future commissioning must be in line with the Better Together Re-Commissioning planning. Page 20

22 Appendix 1 Bibliography Transforming Participation in Health and Social Care, Patients and Information Directorate, NHSE, September 2013 ref Putting Patients First, NHSE Business plan, 2013/ /16 Thanks for the Petunias: A guide to developing and commissioning non-traditional providers to support the self management of peoiple with long term conditions, Diabetes UK, 2011 NHS Year of Care 2014, Better Together Proactive and Urgent Care Proposal, 2013 (Mansfield and Ashfield CCG) NHSE, House of Care, 2014 Self Care forum.org, What do we mean by self care and why is it good for people? NHS Choices, Your Health, Your Way, Your NHS Guide to long term conditions and self care, What is self care? The Health Foundation - Personcentredcare.health.org.uk BMJ Editorial, Thinking about the burden of treatment, BMJ 2014;349:g6680 NHS Choices NHS England Five Year Forward View, Oct 2014, NHSE. Page 21