Working Together to Improve Respiratory Care in Ayrshire & Arran, Scotland     Erica Reid Alison Anderson Carol Nixon Hans Hartung

Project Overview People with long term conditions receive care from a variety of health and social care professionals Care often experienced as fragmented and disjointed Aim to improve integration of care and pathways from a patient perspective Using a trio of methods to test an innovative approach for identifying and testing improvements ‘Person-Centred Approach to Health and Social Care Integration’ 1 year Innovation Project Funded by Health Foundation Patients with COPD

Trio of methods Integration measure – 74-question survey completed by patients Relational coordination – 7-question survey completed by health and social care teams and patients Quality improvement – use survey results to identify areas for improvement – using IHI improvement methodology

Integrated Patient Care By integrated care, we mean care that is Coordinated across professionals, facilities, & support systems Continuous over time and between visits Patient centered, i.e., tailored to patient & family needs & preferences Based on shared responsibility between patients & caregivers -Adapted from Singer et al., 2011 .

Integration survey results 1003 people invited to complete survey 500 replies (50% response rate overall)

Good examples General Practice team knowledge about the patient and medical history 75% patients reported that the healthcare professionals they saw in their General Practice team usually or always seem informed and up-to-date about the care they get from specialists 76% patients felt their General Practice team had good or excellent knowledge of their values and beliefs that were important to their care Specialist knowledge of patient 67% patients reported that when they see a Specialist, he or she definitely seems to have enough information about their medical history

General Practice team knowledge of patient & medical history Opportunities General Practice team knowledge of patient & medical history Specialist knowledge Test result communication In last 12 months how often did someone in the General Practice team contact you between visits to see how you were doing? 5% of people responded ‘Always’ Support for self-management Medication Support & Home Health Management Support & knowledge after hospitalisation

General Practice team knowledge of patient & medical history Opportunities General Practice team knowledge of patient & medical history Specialist knowledge Test result communication After your most recent hospital stay did someone from the General Practice team contact you to see how you were doing? 39% of people responded ‘Yes’ Support for self-management Medication Support & Home Health Management Support & knowledge after hospitalisation

Relational Coordination Survey Efficiency Quality Good user experience Jody Hoffer-Gittell 2009

Our Relational Coordination Survey Questions Paper copies on each table

RC Survey Response Rates

RC Survey Results – All responses Within Workgroups Between Workgroups Weak <4.1 <3.5 Moderate 4.1 - 4.6 3.5 - 4.0 Strong >4.6 >4.0 Green denotes characteristics of high performing teams, so any areas that are not green are target areas for improvement

RC Survey Results – Responses from People living with COPD When we look at results only from people living with COPD – ‘Frequent Communication’ is strong but timely, accurate and problem solving communication is weak. Mutual respect is moderate Within Workgroups Between Workgroups Weak <4.1 <3.5 Moderate 4.1 - 4.6 3.5 - 4.0 Strong >4.6 >4.0 Green denotes characteristics of high performing teams, so any areas that are not green are target areas for improvement

RC Survey Results: Average ties map based on all responses

RC Survey Results Strong & Weak Ties Map

Also… Challenges Highlights Essentials Learning Points 1. Data sharing 2. Conversation with individual practices 3. Improvement and transformation 4. What’s next? Adaptation of integration survey RC as a framework Continuous improvement

…..this is just the beginning Finally… Integration of care services through the user’s perspective. Quality of relational interdependencies as driver of good service experience Improvement and transformation with the person and relationship building at the centre …..this is just the beginning

Thank you