integrated care matters #icmatters · summary of results » number of admissions: – 2015/16: 70%...

A movement for changewww.integratedcarefoundation.org @IFICinfo

Integrated Care Matters

#ICMatters

A movement for change

International Foundation for Integrated Care

IFIC is a non-profit members’ network that crosses

organisational and professional boundaries to bring people

together to advance the science, knowledge and adoption of

integrated care policy and practice.

The Foundation seeks to achieve this through the

development and exchange of ideas among academics,

researchers, managers, clinicians, policy makers and users

and carers of services throughout the World.

A movement for change

‘Integrated Care Matters’

Monthly Webinars

• User and carer perspectives

• Home and Away presentations

• Facilitated Discussion – add questions & reflections to chat box

• Knowledge Tree - Topic based resources developed for each session – send your resources to Marie: marie@hmcic.uk for uploading. A copy of this will be sent out to all registered following the Webinar today

• SIGs are in development and will be hosted on the IFIC Website, if not already done so, please sign up for IFIC membership – a community membership is free if you don’t want to join as a full member

• Up and coming Webinars

• Webinars are in collaboration with UWS, Alliance & HIS

A movement for change

Housekeeping

• Can all participants that are not presenting, please mute

your microphone on the top bar:

• Can hosts & presenters please mute their microphone

when not speaking

• When presenting, please use the arrow buttons at the

bottom of the screen to move through your slides

• Add your questions, comment and reflections to the chat

box

Alison BunceProgramme Lead

Public Health Approach to Palliative Care

Making death, dying and bereavement everyone’s business (Kellehear, 2005)

• a normal part of life

• more than a medical responsibility

• a Public Health and Societal Issue

• a responsibility of a ‘compassionate community’

(Pugh and Aungiers, 2015)

Death and Dying is:

Professor Allan Kellehear

Compassionate Communities Conference

Interested people / Partnership working

Inspiration

Policy Direction

Communities are stronger, responsible and more able to identify, articulate and take action on their needs and aspirations to bring about an improvement in the quality of community life . (2013)

People know how to help and support each other at times of increased health need and in bereavement, recognising the importance of families and communities working alongside formal services. (2016)

Communities of all kinds are empowered to provide effective support to those dealing with death, dying, bereavement and loss. (2011)

“ A Compassionate community is a community where everybody recognises that

We all have a role to play in supporting each other in times of crisis and loss.

People are ready, willing and confident to have conversations about living and dying well and to support each other in an emotional and practical ways”

(2016)

Role of palliative care

Compassionate Communities

Local Initiative, Part of a Global Social Movement

Compassionate Inverclyde

What it is

• Social Movement

• Involves ordinary people

• Community development

• Needs based evolution, with no blue print development

What it is not

• A service

• About health professionals

• A palliative care service

• Prescriptive

Public Engagement

Building Community Capacity

• Improving well being

• Compassionate citizens (No One Dies Alone)

• Work with schools / Annual public event (toabsentfriends)

• Compassionate Organisations

Improving Wellbeing

No One Dies AloneCompassionate Companions

To Absent Friends

Initiatives with schools

Progress so Far

• Initial Public engagement (over 200 people)

• Formation of a Compassionate Inverclyde Board and external support network

• 4 Pilot Groups: Improving Wellbeing Programmes which will be known as HIGH 5

• 1st pilot Bereavement Café at Branchton Community Centre

• 1st working group meeting for No One Dies Alone Programme at IRH

• 1st community ‘toabsentfriends’ event 7 organisations took part

• 1st meeting with Education about working with young people and parents

Current Partnerships

• West College Scotland, Lecturer Emma Maxwell is taking forward the High 5 Programme currently running 2nd public group at Branchton Community centre.

• Branchton Community Centre. Manager Willie Wilson providing accommodation and beverages free of charge for Bereavement Café and High 5 group.

• Your Voice, Staff have helped facilitate public engagement and developed thefilm for the Launch event.

• Inverclyde Council dedicated a tree for the absent friends event in the Well Park.

• Inverclyde Royal Hospital, pilot of the No One Dies Alone programme.

• Initial discussions with colleagues in Seville.

Compassionate

Inverclyde

Every person in Inverclyde will take part in a

‘toabsentfriends event’

100% of churches will have an end of

life care group

Every community centre in

Inverclyde will have a

bereavement cafe

100% of people in IRH will not die alone if that is

their wish

Every community centre will have a resource bank of Compassionate

Citizens

Art gallery, museum and

Beacon Arts center will showcase

Art/drama work

Vision for Inverclyde as a Compassionate Community

100% of organisations in Inverclyde will have a

bereavement policy in place

At least 50% of people in Inverclyde will die in

their place of choice

Every school in

Inverclyde will run the wellbeing

programme

Gp’s and Primary

care teams know how to make a

request for support

Ottawa Charter of Community Developmenthttp://www.who.int/hpr/NPH/docs/ottowa_charter_hp.pdf

• Building healthy public policy

• Creating supportive environments

• Strengthening community action

• Developing personal skills

• Reorienting health care services toward prevention of illness and promotion ofhealth

EvaluationWhat does success look like?

Compassionate = Acts of Kindness

Helpful = Say YES to help

Neighbourly = Ordinary people

Learning from Australia: A Call to Action

• As an Individual• As a Community• As an Organisation

• We are all in it together

• Now in a period of radical change

• We need to think about Network Focussed Care

• Active Hope

• This is the start of a Social Movement

• Death Literacy

Important Facts

Fife Palliative Care Service Webinar

Fiona Mackenzie

Clinical Services Manager

April 2017

The Fife Specialist Palliative Care Service

Fife has a population of around 360,000 people.

» 2 inpatients hospice units - 9 +10 beds

» 2.6 wte consultants and 3 wte Associate Specialists / Specialty Drs

» 7 wte Community Nurses and 2 wte Hospital support nurses

» Children and Families worker and Bereavement Counsellor

» Team of AHPs working across the health system

» Chaplaincy

» Pharmacist

Service Aims

We have developed a work plan for 2017

• that may stretch us

• that we believe we can confidently deliver through our collective practice

• that will support improved service delivery in the context of our local situation, local and national strategic priorities.

...... and we will do this in a way that models asset based compassionate care.

Service identified priorities » Acute care setting – improving the provision of palliative care

across all areas and clarity of roles of the specialist team

» TCAT – use resources creatively to build new ways of working

» Future planning to include other sources of funding

» Need to measure outcomes/ data/IT systems

» Improve MDT working – more structured, dedicated time and place.

» Early intervention/ supported self management

» Ability to prioritise patients better / criteria

» Demands and resource concerns = need for more staff

» Education and training across the system

Our plan must......

» Deliver measurable change

» Maximise existing resources

» Ensure that external sources of funding are explored and secured

» Build sustainability

» Learn from evidence and patient feedback

Strategic Documents

» The Strategic Framework for Action - Palliative and End of Life Care 2016-2021

» The Strategic Plan for Fife (Health and Social Care) 2016-2019

» NHS Fife Clinical Strategy – Palliative Care and Care in the last days of life

.... and there’s more

» The Primary Care Out of Hours Review – Sir Lewis Ritchie» Beating Cancer – Chapter on Living with and beyond Cancer » The National Clinical Strategy» CMO Report -Realistic Medicine » 2020 vision – Describes a Health and Social Care system

focussed on prevention, anticipation and supported self management

» Health and Social Care Partnership Workforce and OD Plan (2016- 2019)

Fife Clinical Strategy

Recommendations:» Improved Identification of people who may benefit from palliative

and end of life care

» Timely sensitive and focussed conversations

» Improve competence and confidence of all health and care staff

» Communication and information transfer across all stakeholders including patients and families

» Seven day generalist palliative care provision

» Seven day specialist palliative care provision

E-health Lead FMcK

Aim- to consider spec and options re ehealth applications for the service and

how the information sharing that has been established under TCAT can be

developed

OOHs Lead LE

Aim - to work alongside PCES ensuring that

Palliative Care needs are taken into account in the

workplan and the service's involvement in future

model

Acute Hospital Support Lead KS

Aim - to work with acute colleagues to support programme of improvement in Palliative Care provision for hospital inpatients.

Explore external sources of funding

Inpatients Nursing Model and Facilities Lead CC

Aim - to review roles within the inpatient areas to ensure all professional roles are being

developed to maximise available workforce working towards extended hours for admission

to hospices

Specialist Community Nursing (CSPCN) Lead

CC

Aim - to review roles and Team leadership CSPCN's

taking into account also the roles of Hospital

Support Team. Involvement of district

nursing/specialist nurses

A&C Review Lead ED/FMcK

Aim - to review A&C needs of the service

DEVELOPING A NEW MODEL

FOR

PALLIATIVE/BEST

SUPPORTIVE CARE

Participation, Improvement

and Review Lead FMcK

Aim – to ensure patient and

family experience drives change

and that research opportunities

encouraged

Workforce Development

Lead FMcK

Aim – To improve confidence

and competence of all staff

Transforming care after treatment ( TCAT) - The new model for Best Supportive Care

1. Robust identification and referral to specialist palliative care within 24 hours

2. Comprehensive palliative care assessment

3. Care coordination including sharing information with other health and care professionals

4. Individualised follow up with regular reassessment of need and carer/ family support

The new model in practice

» See all patients with Lung cancer who are for Best Supportive Care, referral:

– After Lung MDT, occasionally before if unambiguous– Later in diagnosis (e.g. progressive disease after treatment)

» Seen for initial Holistic Needs Assessment and letter dictated

– In clinic, if able to attend, in community, or in hospital ward

» All followed-up by Community Palliative Care Team» Unnecessary follow-up cancelled (Out Patients Appointments )

» E-alert on record – patients identified/seen if admitted

Summary of results» Number of admissions:

– 2015/16: 70% had 1 or more admissions between MDT and death

– 2012: 75% had 1 or more admissions between MDT and death

» Number of bed days:

– 2015/16: 624 bed days for 103 patients

– 2012: 1079 bed days for 99 patients

– 32% reduction in acute bed days

» 67 unnecessary outpatient appointments cancelled (for 99 patients, so many more for wider group)

» Patients and families felt supported

Results

» In 2012 only 57% were seen/called by palliative care compared to 91% in new pathway

» In 2012: average (median) 8 days time to referral compared to 0 days from MDT in the new pathway

The change in pathway resulted in significant cost saving to the health system in respect of cancelled appointments / diagnostics and bed days, at the same time improving quality and experience for families and patients.

Progress

» Workforce – first ANP at recruitment, and working to develop skill set of inpatient band 6 nurses. Reviewing role of community nurses

» E health – early stages but identified key areas re e alerts and core performance data

» Building new models based on TCAT learning – some additional internal funding identified to sustain Lung model and start to spread to other cancer and non cancer groups.

What’s next

» Continue to redesign nursing workforce model

» Continue to explore ehealth solution

» Programme of Improvement activity linked to Commitment 1, building on local and national evidence.

» Seek other funding to spread the model to other cancer and non cancer groups

» Improve OOHs pathways

Creativity matters

SEVILLE CONTIGOCompassionate City

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Our Mission: The New Health Foundation

is to help builda society committed to the

care and attentionof those who need it most.

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Charter for Compassion in Palliative Care PHPCICompassionate Community

✓ Develop policies towards Palliative Care✓ Assure access to PC resources to those living in advanced stage of disease or end of life.✓ Give support to cope with death, mourning and Palliative Care services✓ Respect social and cultural differences✓ Promote awareness campaigns about Compassion, Community and grieving

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TODOS CONTIGOA global community

united by theCALL OF CARE

A different and involved society

A sustainable social model

Retrieve the value of caring

An enduring story

A legacy that can grow

Believing in our meaning as human beings.

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How do we do it?

Aw

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•Talks

•Works

Trai

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•Courses

Res

earc

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Imp

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•Identifyn

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COMPASSIONATE CITIES WORLD MAP

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®CALIDAD SOCIAL Y SANITARIA

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SEVILLA CONTIGOCiudad Compasiva

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C A L I D A D S O C I A L Y S A N I T A R I A

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Seville counts with the support and implication of the City Council for the development of Seville

Contigo, compassionate city

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“I'LL TAKE CARE OF YOU”THE LANGUAGE OF CARE

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P H O T O C O N T E S T ” t a k i n g c a r e o f y o u "

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COMPASSIONATE SCHOOLS

®CALIDAD SOCIAL Y SANITARIA

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J O R N A D A S “ E L P R I V I L E G I O D E P E R M I T I R S E S E R C U I D A D O ”

Training Workshops

for the community

- P a l l i a t i v e C a r e- R i g h t s , n e e d s a n d f e a r s- E v o l u t i o n o f i l l n e s s- G r i e f- C o m m u n i c a t i o n t e c h n i q u e s

®CALIDAD SOCIAL Y SANITARIA

© 2016

®CALIDAD SOCIAL Y SANITARIA

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P I L O T E P R O J E C T . S A N P A B L O - S A N T A J U S T A . 6 0 . 0 0 0 p e o p l e .

®CALIDAD SOCIAL Y SANITARIA

© 2016

How does a Compassionate “With You” City work?

Associations

Social Workers: Detection and Activation

Patients

Personal Social Network:

FamilyNeighbours

Friends

COMMUNITY PROMOTERS

Volunteers

Collaborating Centres

Case Detection:• Health centres.• Social Services. • Hospitals• PC team• Residences• Parishes• Collaborating centres

a)

b)

(A,T,I)

(A,T,I)

(A,T,I)

(A,T,I)

Previous:A: AwarenessT: trainingI: Implementation

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SEVILLE CONTIGOCompassionate City

when “No one can do anything” ....WE can make the difference

®CALIDAD SOCIAL Y SANITARIA

© 2016

Cristina Castillo Rodríguez. cristina.castillo@newhealthfoundation.org

A movement for change

Virtual Blether – What Matters with Mandy Andrew

Mandy Andrew

iHub Network Development Lead,

Healthcare Improvement Scotland

A movement for change

Community Centred Palliative Care

Knowledge Tree Branch

Marie@hmcic.uk

A movement for change

Next Webinar Dates for Your Diary

Building community connections and resilience: the important of contacts and culture Tuesday, 16 May 12:00pm – 1:00pm

Alison Linyard, SHINE Project, FifeProf David Perkins, Centre for Remote and Rural Mental Health, University of Newcastle, Australia

Volunteer presenters for future webinars welcome

Contact: anne.hendry@lanarkshire.scot.nhs.uk

A movement for change

Compassionate

Communities Symposium

Compassionate Communities Symposium

Published on 20 Feb 2017

Highlights from the 2017 Compassionate Communities Symposium at ICC Sydney.

Hosted by Palliative Care Australia and The GroundSwell Project.

A movement for change

Stay connected and grow our Integrated Care Matters

Learning Community

• Join us at:

• Tweet #ICMatters

• Blogs – share your thoughts and experience

• Knowledge Tree: Add your resources and grow our tree.

Send resources to Marie at: marie@hmcic.uk

• Involve your colleagues in future webinars

• Visit the WHO portal http://integratedcare4people.org/

Thank You