11 November 2014 Our Approach in Community Services Sara Hill, Podiatry Business Manager/Clinical Lead Jo Wallis, Senior Community Physiotherapist Jo Hood, Podiatry Service Development Lead Debbie Beales, Lead Nurse Coronary Heart Disease Service Jo Reid, Physiotherapy Team Leader What patients want from talking with their clinicians Angela Coulter Senior Research Scientist Nuffield Department of Population Health, University of Oxford

INFORMATION, INVOLVEMENT, SUPPORT What Patients Want Angela Coulter Health Coaching conference Lynford Hall, November 2014

Person centred coordinated care “I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.” Information My goals/outcomes Communication Decision making Care planning Transitions

Managing Long Term Conditions Professional care – 5 hours per year Self-care – 8,755 hours per year

Diabetes Web of Care

Alzheimer’s Web of Care

Were you involved as much as you wanted to be in decisions about your care and treatment? % % responding ‘Yes, definitely’ Source: NHS inpatient surveys

Care and Support Planning Personalised care planning aims to ensure that individuals’ values and concerns shape the way in which they are supported to live with and self-manage their long- term condition(s)

Engaged, informed patients HCPs committed to partnership working Organisational processes Responsive commissioning Personalised care planning Coulter, Roberts, Dixon: Delivering better services for people with long-term conditions – building the House of Care, King’s Fund, October 2013

What Patients Need to Know What are my options? What are the benefits and possible harms? How likely are these benefits and harms? What are your goals, do they match mine? What can I do to help myself? What can you do to support me?

Sharing Expertise Clinician Diagnosis Disease aetiology Prognosis Management options Outcome probabilities Patient Experience of illness Social circumstances Attitude to risk Values and preferences Goals

One-time Decisions for Tests or Treatments Wellness and Health Promotion Decisions Chronic Care Management Decisions Personal Care Planning Shared Decision Making

Care Planning Consultation Patient’s agendaProfessional’s agenda Goal setting and action planning Information sharing Agreed and shared care plan Information gathering Information sharing

14 1. Preparation 2. Goal setting 3. Action planning 4. Documenting 5. Coordinating 6. Supporting 7. Reviewing Care planning cycle

TEAMcare, USA Aim: To improve outcomes for patients with major depression and poorly controlled diabetes, coronary heart disease or both by developing a patient-centred, primary care-based, care management intervention for multiple conditions

TEAMcare Tools Collaborative goal-setting and action planning Evidence-based pharmacotherapy Structured consultations and monitoring every 2-3 weeks with physician or nurse Proactive nurse follow-ups to support self-care using motivational interviewing, problem- solving techniques and maintenance plans Staff training and weekly supervision

TEAMcare – Results Improvements in: HbA1c Cholesterol Blood pressure Depression Quality of life Confidence to self-manage Cost-effectiveness Katon 2010, von Korff 2011, Lin 2012, Katon 2012, Ludman 2013

Systematic Review of Personalised Care Planning 10,000 abstracts scanned 43 articles included describing 19 unique studies (RCTs) USA (13 trials), Australia (1), China (1), Denmark (1), Netherlands (1), Taiwan (1), UK (1)

Participants and Settings 10,856 participants Diabetes (12 trials), mental health (3), heart failure (1), end-stage renal disease (1), asthma (1), various conditions (1) Primary/community clinics (17) Hospital clinics (3)

Interventions Aims – behaviour change among patients (19) Behaviour change among patients AND clinicians (4) Goal setting, action planning, follow-up (19) Tools – information packages, structured consultations (coaching), peer support, group visits Clinicians – nurses/therapists (14), doctors (6), peer coaches (2), mental health providers (2)

Outcomes Physical health Psychological health Subjective health status Self-management capabilities Health-related behaviours Resource use Adverse effects

Outcomes Physical health:  blood glucose control Psychological health:  depression Subjective health status:  mixed Self-management capabilities:  self-efficacy Health-related behaviours:  mixed Resource use:  mixed Adverse effects:  none

Care Planning Works Best When it is ……… Comprehensive (all 7 stages of care planning cycle) Higher intensity (longer duration (> 3 months), more contacts) Integrated with usual care Well supported (training, supervision and support for clinicians as well as patients)

What We Have Learnt Traditional practice styles……. Create dependency Discourage self-care Ignore preferences Undermine confidence Do not encourage healthy behaviours Lead to fragmented care

Informed, Empowered Patients Have the knowledge, skills and confidence to manage their own health and healthcare, And they…… Make healthy lifestyle choices Make informed and personally relevant decisions about their treatment and care Adhere to treatment regimes Experience fewer adverse events Use less costly healthcare Health Affairs Feb 2013

The Greatest Untapped Resource