Care Pathway Planning. Comprehensively simple

Transcription

1 Care Pathway Planning Comprehensively simple

2 What is a Pathway? We talk about pathways a lot. But what do we really mean? The planned route that enables a patient to get safely to the right end destination in the shortest reasonable time. There s no point in just having a clear pathway in place. It s also necessary to have a realistic plan about how to navigate the pathway. PathNav is an application designed by PiC to build and review that plan with patients, but however you do it, the principles are the same.

3 Construct of a Care Pathway Plan The plan (or Care Plan) might include: 1.Context for how you arrived at the start of the journey, what s going to help you along the way, and what s going to impede your progress. Who are you traveling with, and what do they bring? (Formulation/Needs Assessment) 2.Clarity about the end destination & the route you re taking (Pathway map) 3.Knowing what you need to do to get from point to point in the journey (Health outcomes/goals) 4.A training plan. What skills and abilities am I going to need to accomplish the journey? (Activity/Therapies) 5.What s the plan if I get ill or need help along the way? (Support plans)

4 Construct of a Care Pathway Plan The plan (or Care Plan) might include: 1.Context for how you arrived at the start of the journey, what s going to help you along the way, and what s going to impede your progress. Who are you traveling with, and what do they bring? (Formulation/Needs Assessment) 2.Clarity about the end destination & the route you re taking (Pathway map) 3.Knowing what you need to do to get from point to point in the journey (Health outcomes/goals) 4.A training plan. What skills and abilities am I going to need to accomplish the journey? (Activity/Therapies) 5.What s the plan if I get ill or need help along the way? (Support plans)

5 2. Destination & route Learning: Testing with clinical teams shows that for most patients it is possible to make a reasonable judgement about the final and most realistic point in a patient s journey.

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7 2. Destination & route Learning: Testing with clinical teams shows that for most patients it is possible to make a reasonable judgement about the final and most realistic point in a patient s journey. When you have mature, multi-disciplinary and evolved clinical teams it s not at all difficult. Where the problems arise is when teams are suffocated by feeling they need to use all parts of the pathway. Most often, patients value seeing the full picture of their journey and the services they ll use. It often repositions their ideas of the next point in the pathway. It does demand though, that we re more open about those patients who are likely to reach the limit of their integration with the community in inpatient services. We ve referred to this as enduring care.

8 3. Health outcomes

9 3. Health outcomes Patient experience measures Factors a person feels are important to their care or to the experience they have while in care. Patientdefined experience measures do not always fit perfectly with health outcomes but should always be listened to and where possible taken into account. Risk management arrangements Special Arrangements to prevent, minimise or manage understood risks. i.e. 1 1 observation, access to high risk items or observation of visits etc. Life goals/aspirations and hopes Important goals people want to accomplish in life or ideals they wish to uphold. These should be properly understood by a clinical team and supported where it is reasonable to do so. Personal support arrangements Special Arrangements to support personal care, physical health or other cultural/personal needs etc. i.e. personal care plan, detailed chronic condition plan etc. Interventions Treatment and therapy packages that might (or might not) support health outcomes i.e. CBT. Completion of intervention does not necessarily mean a health outcome has been achieved. Health outcomes The specific health result a patient and clinical team need to achieve (or contribute to) together to enable the treatment pathway to be completed. They need to be specific, measurable and fair.

10 3. Health outcomes Patient experience measures Factors a person feels are important to their care or to the experience they have while in care. Patientdefined experience measures do not always fit perfectly with health outcomes but should always be listened to and where possible taken into account. Risk management arrangements Special Arrangements to prevent, minimise or manage understood risks. i.e. 1 1 observation, access to high risk items or observation of visits etc. Life goals/aspirations and hopes Health outcomes Important goals people want to accomplish in life or ideals they wish to uphold. These should be properly understood by a clinical team and supported where it is reasonable to do so. Personal support arrangements Special Arrangements to support personal care, physical health or other cultural/personal needs etc. i.e. personal care plan, detailed chronic condition plan etc. Interventions Treatment and therapy packages that might (or might not) support health outcomes i.e. CBT. Completion of intervention does not necessarily mean a health outcome has been achieved. The specific health result a patient and clinical team need to achieve (or contribute to) together to enable the treatment pathway to be completed. They need to be specific, measurable and fair.

11 3. Health outcomes I can identify risk factors as they arise and manage them to make sure I don t relapse My symptoms are well controlled with treatment and/or medication I take my medication when I should without prompting and I can do this reliably on my own I can manage my frustration without the problem behaviours emerging I have demonstrated I can stay risk-free unsupervised in the community I've succeeded at quitting smoking

12 3. Health outcomes Learning: Health outcomes map over the entire pathway. There aren t outcomes for medium secure and outcomes for low secure. There are outcomes for patients. Defining the progress points (or steps) within an outcome in relation to the pathway is really important. Grading 1-5 just isn't good enough.

13 3. Health outcomes map over the pathway

14 3. Health outcomes Learning: Health outcomes map over the entire pathway. There aren t outcomes for medium secure and outcomes for low secure. There are outcomes for patients. Defining the progress points (or steps) within an outcome in relation to the pathway is really important. Grading 1-5 just isn't good enough. Distinguishing which health outcomes are Pathway critical and which you can take with you are really important.

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16 Clarity about the destination?

17 3. Health outcomes Learning: Health outcomes map over the entire pathway. There aren t outcomes for medium secure and outcomes for low secure. There are outcomes for patients. Defining the progress points (or steps) within an outcome in relation to the pathway is really important. Grading 1-5 just isn't good enough. Distinguishing which health outcomes are Pathway critical and which you can take with you are really important. Static outcome tools miss an opportunity to be helpful. Being able to bin outcomes that aren't relevant and being able to write patient specific outcomes is critical to any outcome tool being safe, clinically sensitive and personalised.

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19 3. Health outcomes Learning: Health outcomes map over the entire pathway. There aren t outcomes for medium secure and outcomes for low secure. There are outcomes for people. Defining the progress points (or steps) within an outcome in relation to the pathway is really important. Grading 1-5 just isn't good enough. Distinguishing which health outcomes are Pathway critical and which you can take with you are really important. Static outcome tools miss an opportunity to be helpful. Being able to bin outcomes that aren't relevant and being able to write patient specific outcomes is critical to any outcome tool being safe, clinically sensitive and personalised. Making a clear link between interventions and outcomes is important. We ve moved well beyond the arbitrary 25hrs of activity.

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21 Summary Having a clear pathway is critical, but it s only part of a much more comprehensive approach Clearly stated heath outcomes are essential to transitions - knowing what to reach for and knowing when it s ok to move on Care plans, recovery plans, CPA plans call them what you like but patients most probably only need one comprehensively simple plan Successful pathways also need to be clinically efficient. Building a process that takes more clinical time to administrate prolongs journeys rather than shortens them.

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