integrated care matters #icmatters · summary of results » number of admissions: – 2015/16: 70%...
TRANSCRIPT
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: [email protected] 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
®
Our Mission: The New Health Foundation
is to help builda society committed to the
care and attentionof those who need it most.
®C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®CALIDAD SOCIAL Y SANITARIA
© 2017
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
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®CALIDAD SOCIAL Y SANITARIA
© 2016
®CALIDAD SOCIAL Y SANITARIA
© 2016
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.
53
How do we do it?
Aw
arn
ess
•Talks
•Works
Trai
nin
g
•Courses
Res
earc
h •Monitor the
Imp
lem
enti
ng
•Identifyn
®CALIDAD SOCIAL Y SANITARIA
© 2015
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
COMPASSIONATE CITIES WORLD MAP
®CALIDAD SOCIAL Y SANITARIA
© 2016
®CALIDAD SOCIAL Y SANITARIA
© 2016
SEVILLA CONTIGOCiudad Compasiva
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
Seville counts with the support and implication of the City Council for the development of Seville
Contigo, compassionate city
®C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
“I'LL TAKE CARE OF YOU”THE LANGUAGE OF CARE
®C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
60
6
1
®CALIDAD SOCIAL Y SANITARIA
© 2016
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 "
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
COMPASSIONATE SCHOOLS
®CALIDAD SOCIAL Y SANITARIA
© 2016
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
© 2016
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
®
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
®
C A L I D A D S O C I A L Y S A N I T A R I A
© 2 0 1 6
SEVILLE CONTIGOCompassionate City
when “No one can do anything” ....WE can make the difference
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
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: [email protected]
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: [email protected]
• Involve your colleagues in future webinars
• Visit the WHO portal http://integratedcare4people.org/
Thank You