Improving Patient Enablement & Continuity of Care (IPECC) Purpose: To create a culture of patient enablement in hospital, through enhancing professional and organizational interfaces and education. Cathy Yuill Emma Ellis Hazel Lamb Jo Skeets

Shared Decision-Making IPECC Project Overview (HE SW) Aim: Create an enhanced culture of patient enablement to maintain functional skills and independence throughout an individual’s acute stay in hospital. Acute Hospital Patient Enablement Aim: Develop a trusted assessment process and interface between Nursing, Occupational Therapy, Physiotherapy and Social Work. Trusted Assessment and Interface Aim: Improve the interface and continuity of care between hospital and community therapy and Social Care services. Shared Decision-Making The IPECC Project was funded by Health Education South West and was running from May 2015 until the end of September 2016. The 3 main aims of the project were: Acute Hospital Patient enablement: This is the practice based enablement training programme completed with Health Care Assistants (HCA’s). Trusted Assessment and Interface: This relates to the functional laminate project. Shared decision making: With D2A pathways, Nursing staff are expected to make decisions about patient discharges and whether they are ‘safe between visits’ with community follow-up, without the traditional acute therapy assessment. We have linked with hospital and community staff involved in D2A to develop an e-learning package to underpin Discharge planning and D2A. Practice-Based Teaching Health Coaching Enablement E-Learning Functional Laminate Discharge E-Learning

Practice-Based Enablement Training Purpose: To create a model of practice-based teaching of enablement for Health Care Assistants working on the acute wards.

What is enablement? Enablement is supporting people, not by doing things for them, but by working in partnership with them and encouraging them to be as independent as possible. Enablement is carrying out activities in partnership with patients, not for them, to promote independence. Enablement focuses on maintenance of functional skills in daily activities. Enablement links closely with person centered care and recognises the value to patients participating in normal routines and activities to maintain independence during a hospital stay.

Why Enablement? Prevent complications associated with deconditioning – the vicious cycle! Muscle Weakness Chest infections Pressure Sores Increase risk of falls Reduced Confidence Staying in bed for a long time or “bed rest” can lead to complications including Muscle Weakness, Chest infections and pressure sores. This can cause reduced exercise tolerance and general deconditioning for patients. Inactivity can increase a patients risk of falling and reduce their confidence. For older people, it only takes a week of bedrest to loose up to 30% of their muscle strength. When the patient finally gets out of bed they find it much more difficult because of all of the above, making them more reluctant to be active. This can make them even more deconditioned – it’s a vicious circle! All this can make it more difficult for the patient to manage things that they may have been previously independent with such as washing and dressing and mobility, requiring a longer period of recovery after illness and increasing length of stay in hospital. It takes a lot longer to re-build the strength than it did to loose it! Improved patient participation and experience both in hospital and surrounding discharge.

Practice Based Enablement Teaching Piloted on two wards. Meetings with HCA’s to identify learning needs. Practice-based teaching on the ward with ‘real’ patients. Role modelling/Lead by example. Demonstration of competence. Measurement Pre- and post-training evaluation Before and after observation of HCA practice. Rated against behaviours that promote enablement. Survey Monkey questionnaire before and after. This was the structure of the training with HCA’s on two wards – frail elderly and stroke acute rehabilitation: Initial training session Presentation on theory and background of enablement. Training sessions on the ward Using Role Modelling/Leading by example Observation of HCA’s practice and constructive feedback given. Dedicated time to sign off competencies and agree priorities for next session. Practical interventions: HCA’s finding out patients home situation and normal routines. HCA’s finding out patients current functional abilities and promoting this during interactions: Getting out bed and washing in the bathroom. If patient safe to be left alone, HCA’s completing paperwork, bed making etc. whilst monitoring patient. Walking to toilet instead of using commode Reducing “automatic behaviours” such as pulling down patient pants or putting on clothing without giving patient chance to do it themselves.

Summary Results: HCA Enablement Training on 9B Baseline 59.64% increase in enabling indicators sustained. This shows the average score for all the enablement behaviours observed before training, after training and 1 month on. The baseline highlights that the HCA’s did not start at 0 as they were using a degree of enablement in their practice before the training. These results have been averaged across 8 HCAs observed during 3-4 interactions per observation period. We found an almost 60% increase in enablement behaviours from before the training to one month after the training. This was rated for each enablement indicator: Giving choice Promoting participation in normal routines Treating the patient as an equal Awareness of patient priorities and goals Communication to promote participation and independence Documentation of functional abilities (removed for 9A as we felt this should be separate)   TOTAL (mean average - max 3) Before Training 1.43 After Training 2.57 One Month On 2.29 Percentage Increase 59.64% In Summary: Enablement Behaviour Increased 0 – No evidence observed. 1 – Evidence observed less than 50% of the time. 2 – Evidence observed 50-75% of the time. 3 – Evidence observed over 75% of the time.

Feedback From Staff - I feel much more confident to encourage people (I am less afraid that they will fall). - I feel confident to explain to the patient about the importance of enablement …. to speak to my colleagues about enablement and the importance of it.” (ward 9B) “I have learnt that it is important to give patients a chance to do things for themselves, it helps them for when they leave and it builds their confidence” (ward 9A) This is some positive feedback we obtained from the questionnaires. On the whole, the feedback from HCA’s was very positive. They felt the structure, length and content was appropriate for their role and they were keen and enthusiastic to try out new idea’s. Feedback from Nurses was mixed, most thought it was a good idea in principle but were concerned about the extra time needed. However, I found that it took staff just as long to help a patient as it did to let them do it themselves whilst they monitored them and completed paperwork, bed making etc. Talk about HCA who washed patient on the toilet.

‘Enabling Conversations’ Health Coaching: ‘Enabling Conversations’ Purpose: Implemented practical training of the health coaching framework, with a focus on Stroke Services.

Current Training as part of Health Coaching Pilot Health Coaching training provided to Therapists, Nurses and HCAs on pilot wards. 2-day basic training + 2-day accreditation training. Portfolio development required for accreditation. Develop a ‘train-the-trainer’ programme using a small group of clinicians who received this Health Coaching training. Further staff receive health coaching training.

When patients see a clinician, their consultation may not be working Only a third to a half of patients comply with prescribed medications and 10% with lifestyle advice. Only 60% of patients feel they are sufficiently involved in their care. Not all clinicians are trained in behaviour change. And the evidence is growing that our current approach with patients is not working – how we engage with them, talk with them and support them to change behaviour: Half of patients leave primary care visits not understanding, only 9% of patients participate in decisions, adherence rates for medications and lifestyle changes are ~ 50% and 10% , Clinicians are not trained in the science of behaviour change based on the most recent research. The goals of patients are not given enough recognition in treatment choices, and the benefits of shared decision making and patient and carer involvement are not being realized. Basic communication needs to improve - research shows most Drs interrupt within 12 seconds. The #Hellomyname is campaign illustrates that we need o introduce ourselves While on the whole satisfaction is high complaints are rising. The GMC experienced 104% rise in complaints 2007-2012, with 54% about clinical care or communication. This is because paternalism – being expert driven, authoritarian, and advice-giving “we know best” – while important when patients are acutely unwell, can encourage dependency, is not most effective in terms of behaviour change and patients do not always appreciate it. We need to talk differently. Bennett H, Coleman E, Parry C, Bodenheimer, 2010 KPMG Creating value with patients, carers and communities 2014 GMC Annual report 2013, Rhoades DR, Fam Med 2001. Wolever R, 2013 Coulter A, 2011

Am I being effective?

What is health coaching? Helping patients gain the knowledge, skills, tools and confidence to become active participants in their care, so that they can reach their self-identified health goals Bodenheimer, 2010

Next Steps Developing a ‘roll-out plan’ to begin to embed a coaching culture within the Trust, using the ‘Train-the-Trainer’ Health Coaching of staff Developing a process of evaluation (linking with AHSN and UWE re possible research across the stroke pathway) Linking with the ‘Patient Activation Measure’ Linking with the STP in BNSSG, with alignment to MECC (Making Every Contact Count) Making Every Contact Count (MECC) is an approach to healthcare that encourages all those who have contact with the public to talk about their health and wellbeing. It encourages health and social care staff to use the opportunities arising during their routine interactions with patients to have brief conversations on how they might make positive improvements to their health or wellbeing.

Enablement E-Learning Purpose: Development of an e-learning training programme on patient enablement. This is interactive, and includes photographs and practical video clips. It brings together all enablement information gathered as part of the IPECC project.

The Functional Laminate Pilot Ward 32a Purpose: To pilot the development of a Patient Functional Laminate on an acute ward for older people.

A test of change using functional laminates with patients was completed on ward 32a. The original idea came from the vascular therapy team who were using them with their amputee patients. What is a functional laminate? its an information sheet laminated about a person’s function. The therapists following their assessment take responsibility for completing the form+ with the patient plus family/carer as appropriate and put it on the white board above their bed. The laminate provides (at a glance) information to HCAs and nursing staff about a patient’s function so they can support and be more enabling 24/7 We also think that it will be helpful for patients to understand what is expected of them, as well as their relatives or carers

On the back of the laminate we have explained about it, it’s purpose and included common therapy abbreviations for staff reference. We hope the laminate has three main benefits:- Supports and promotes communication about patient function between professionals and with the patient and their carer. Promotes patient and carer participation in their care. Improves patient experience and reduces complications associated with de-conditioning

Feedback from staff and patients Link therapist reported that communication about patient function between HCA staff and therapy staff has improved. HCA staff reported the laminates were useful in caring for patients providing they were up to date. Patients have been agreeable to have their functional information on the whiteboard. One patient consented to the laminate “if it helped”. Another patient commented “if it helps me get out of hospital quicker”.

Discharge E-Learning: Home is Best! Purpose: Developed a Discharge E-Learning Training Programme for acute clinical (and applicable to relevant non-clinical) staff

During the development process, we have shown the e-learning (either full version or condensed) to: Steve Bunce, Helen Mee (head of IDS), Keirsten Wilson (linking in with NHSI), LHOG, Cathy Daffada (linking with her work on ‘Home is Best’), Jenny Reid (Band 5 Staff Nurse - trial run), and Bev Davies (sister on AMU who sparked the idea of the e-learning). We will also be linking with: Michael Whitmore (Discharge Together), L&D Committee, Enabling Discharge Meeting (presenting on 5th September) We are now finalising the e-learning and it is set to go live in September (planned for 9th September), before the end of the IPECC project. The feedback we have received is that this would be helpful for all clinical staff.

In the e-learning you click on each of these and there’s a longer description of each option. We have added in the additional first question as we had feedback from several people that we need to make it clear that some patients do not need a D2A pathway if they can just go home. Following this, the e-learning provides more information about each of the pathways and then staff have a drag and drop exercise to match each D2A pathway to its description.

(Hovered over safeguarding)

For D2A Pathway 1 Is my patient safe between visits? Count off the 5 key things to think about. Consider their mobility and function. Do they need any equipment? Do they have help at home? Consider their cognitive ability. Will they understand the need to do these activities at home? Will they remember to do them? Consider if the patient had any previous support with these areas. Consider any safeguarding concerns that need to be addressed prior to discharge. If you have any concerns, contact the community team to discuss if Discharge to Assess Pathway 1 can provide support. 1. Access drink 2. Access meds & food 3. Access toileting 4. Wash & dress 5. Call for help This is part of the further information for Pathway 1. The e-learning goes into more detail about each of these points and the things you should consider. Note – the safeguarding concerns comment will be on the downloadable resource at the end of the e-learning.

Added the pre-question to see if they can go home without D2A. We then added a number of case studies for staff to practice their knowledge on, with an assessment at the end.

Project Risks and Issues Trust limitations and delays (e.g. winter pressures) Engagement of staff Time constraints due to trying to implement in a busy acute hospital More detailed documentation to support patient enablement Funding to continue the Health Coaching Co-Delivery training and roll-out of the ‘Enabling Conversations’ training Roll-out and continuation of each aspect of the project Ownership by the CSU with IDS. Improved communication and shared decision-making between hospital and community staff is another benefit addressed through the Discharge E-Learning course.

Any Questions?