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

2. 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

3. 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

4. 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 .

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

6. 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

7. 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

8. 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

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

10. Our Relational Coordination Survey Questions
Paper copies on each table

11. RC Survey Response Rates

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

13. 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
Strong
>4.6
>4.0
Green denotes characteristics of high performing teams, so any areas that are not green are target areas for improvement

14. RC Survey Results: Average ties map based on all responses

15. RC Survey Results Strong & Weak Ties Map

16. 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

17. …..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

18. Thank you