Reliable application of the five Must Do With Me elements: 1. What matters to you? Personal outcomes and goals agreed 2. Who matters to you? Access to and involvement of loved ones 3. What information do you need? Information is timely, full and understandable to facilitate shared decisions 4. Nothing about me without me Involved with communication, handovers and transitions the level they choose 5. Personalised contact Method and timing of contact can flex
The Improvement Guide, API
Improving Conversations at the Point of Care. Dementia Post Diagnosis Support Stephen Lithgow Dementia Support and Development Lead. Greater Glasgow and Clyde.
What were we trying to accomplish? New service. Dementia. One year Post Diagnosis Support. Link worker to support client and family. Using the 5 pillars approach. Personal Plan at end of the year. Focus on Co-production and Outcomes.
Five Pillars of PDS
What were we trying to accomplish? What matters? Listen and Improve conversations. By using Outcomes approach and a Personal Plan. Who Matters? Involving carers/family. Working with both parties. Q. How would these have helped Tommy and his mum?
What did we do? Service with Mental Health Staff. (Community Psychiatric Nurses and Occupational Therapists). Alzheimer Scotland Link Workers. Developed a Personal Plan with an Outcomes Framework for clients and carers. Paperwork to help frame Person Centred Care.
Improve Conversations-Use Outcomes Quality of Life Process Change Feeling safe Having things to do Seeing People Staying as well as you can Living where you want as you want Dealing with stigma/ discrimination Listened to Having a say Treated with respect Responded to Reliability Improved confidence/morale Improved skills Improved mobility Reduced symptoms
Conversations around.. Understanding dementia. Managing symptoms. Seeing people socially. friends and family. Meeting others in a similar situation. Having things to do. Feeling in control. Feeling listened to. Feeling confident. Being treated with dignity and respect. Living as you want. You have planned for future decision making.
How do we record this? 1. Recording conversations. Qualitative. 2. Simple framework to assess progress against outcomes. Quantitative. Unmet -0 Partially met -1 Met-2 Reviewed at 6 months and 12 months. Survey monkey staff and clients.
WORKSHOP Engage what client wants to achieve, strengths, abilities, service contribution, extent outcomes achieved. Record through conversations, other information, professional observations, qualitative. Useof information.individual packages of carer and support, service delivery and improvement, planning/commissioning. How could apply Outcomes to your setting / how could you adapt it? What would a test of change look like? (10 mins)
So What s Different?
Positives. New staff training on Personal Outcomes and dementia PDS. (NHS Education Scotland and Scottish Social Services Commission). More outcomes based conversations and link to Scottish Recovery Indicator2. More staff using a 5 pillars approach. Positive client feedback around process rather than paperwork.
WORKSHOP. What barriers or challenges might you face? (5 mins)
Our challenges. Culture and professional background. Assessment. Focus on deficits. We do that already. Focus on paperwork not process. How do we record all this? We needed training.some resistance.
Thank you. Stephen Lithgow Dementia Support and Development Lead Greater Glasgow and Clyde NHS Stephen.lithgow@ggc.scot.nhs.uk
Are We Talking? Knowing Me Knowing You Sandra Shields Alzheimer Scotland Dementia Nurse Consultant NHS Greater Glasgow & Clyde
Improving Conversations at the Point of Care
Must do with me What matters to you? Who matters to you? What information do you need? Nothing about me without me Personalised contact
What We Did Expert Group Discussion on Amalgamating Various Agendas Using GTKM Carers Agenda Person Centred Care Agenda Anticipatory Care Agenda Care planning for Cognitive Impairment
Issues Too Big to test Document was harder to use than anticipated Communication was vital Carers confidence reported as improved
Workshop Knowing me Knowing You
What we found Too Big to test Document was harder to use than anticipated Carers confidence reported as improved 1 nurse and 1 patient could cause some inconsistencies in communication
2 ND Workshop Making it work in your area.