Intgrated Care Pathways by Katy Gordon, CoCreating Balance

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  • Where this has been done the impact has been dramatic. It has resulted in improved services for patients. It has also resulted in improved productivity, made the task of caring for patients easier for staff & in many cases it has released resources to spend on other services.
  • This picture demonstrates an example of careful planning but the execution of ‘the plan’ shows that ongoing monitoring needs to be in place t ensure that the processes are actually implemented in the right way. It also begs the question ‘why did nobody ask at the time if this was right?’ or was this an addition to a pre-existing building/service which was great in theory but should have been modified in practice?
  • ICPs are both a tool and a concept that embed guidelines, protocols and locally agreed, evidence-based, patient-centred, best practice, into everyday use for the individual patient. In addition, and also unique to ICPs, they record deviations from the planned care in the form of variances.
    ICPs, then, should embrace all of the above for the 8-% majority, thus the 20% represent the variance i.e. they don’t follow the accepted pathway for good reasons. Kaiser-Permanente in the USA have developed this model and the describe it as a 3-layered tier, with the 70 – 80% majority not requiring specialist input as they should be managed in primary care because they are not severely ill. The other 2 levels represent an increasing level of specialist input/ care dependency.
  • But most importantly …..
  • It is this last point that sets ICPs apart from the myriad of other tools supporting best practice.
    A concise definition of an ICP (copyrighted by Venture 2002) is ‘An Integrated Care Pathway is a document that describes a process within health and social care, and that collects variations between planned and actual care.
    An ICP Framework incorporates a systematic cycle of activities based around the development and use of an ICP document to ensure continuous improvements to practice and outcome. These activities include selecting ICPs to use with patient/client groupings, developing ICP content and layout, using ICPs as the contemporaneous patient/client record, recording analysing and comparing any variations from planned activity and outcome, and continuously updating practice as a result.
    ICPs are should contain:
    Multi-disicplinary, multi-agency, clinical and administrative activities
    Evidence-based, locally agreed, best practice
    Local and national standards
    Variance tracking (essential to all ICPs)
    Tests, charts, assessments, diagrams, letters, forms, information leaflets, satisfaction questionnaires etc.
    Scales for measurement of clinical effectiveness
    Outcomes
    Freehand notes
    Space to add activities or comments to a standard ICP to individualise care for a particular patient
    Problem, Plan, Goal and Notes or similar structured freehand area (multi-disciplinary template for recording and variance tracking an individual patient’s problems, goals, plans and freehand notes)
    ICPs always contain structured variance tracking
    More importantly and ICP is NOT:
    A protocol
    A flow chart of events
    A care map
    A process map
    A decision tree
    A guideline
    A care plan
    ICPs may contain protocols and guidelines and they may start their developmental histories as a process map, flow chart or decision tree, but unless they have a mechanism for recording variations/deviations from planned care/activities when used as the record of patients, then they are not a true ICP
    It is essential during the ICP project planning stage to define the scope of each ICP so that it has a clear start & finish point. Well scoped ICPs will facilitate the building up of these ‘bite-sized chunks of service’ into seamless Pcakages of Care for each target patient group.
  • If the pathway isn’t planned down to the last detail professional delivering the care will find ways round parts of the system they don’t like or feel are pointless.
  • Copy/paste pdf file into this of current pathway
    Process mapping event on March 18th to map the ‘front end of the process’ and see how it could best be improved to make an early appropriate diagnosis (or refute the diagnosis).
  • Copy/paste pdf file into this of proposed pathway
    We also developed a proposed ideal pathway – FROM THE PATIENT’S PERSPECTIVE.
  • The project falls into 2 parts:
    The first part is getting registers validated. Numbers on HF registers in the practice I have visited so far are far less than they should be compared to the national average. In order to help get the registers more accurate practices need to be able to state that all their patients have had diagnosis confirmed, thereby giving the patient a greater chance of being on the right medication and titrated to the right dose
    The other part of the project is to setup a PwSI-led community based one stop diagnostic clinic (with some slots for ongoing management/review where it is deemed necessary. At present we run the risk of the GPwSI working as a Clinical Assistant to the cardiology department rather than triaging and managing the service for the majority of patients who can be looked after in primary care.
  • Intgrated Care Pathways by Katy Gordon, CoCreating Balance

    1. 1. Patient PathwaysPatient Pathways Katy GordonKaty Gordon
    2. 2. NHS Plan (DoH 2000)NHS Plan (DoH 2000) • Our aim is to redesign the system aroundOur aim is to redesign the system around the patient….the patient…. • PCTs have been in operation giving localPCTs have been in operation giving local health professionals more freedom tohealth professionals more freedom to develop new services….develop new services….
    3. 3. NHS PlanNHS Plan Patients should have fair access and highPatients should have fair access and high standards of care wherever they live:standards of care wherever they live: National standards for key conditions andNational standards for key conditions and disease through the NSFsdisease through the NSFs Clear guidance on best treatments andClear guidance on best treatments and interventions from NICE to ensure a faster,interventions from NICE to ensure a faster, more uniform uptake of treatment which workmore uniform uptake of treatment which work best for patients.best for patients.
    4. 4. NHS PlanNHS Plan The NHS has started to redesign the way healthThe NHS has started to redesign the way health services work. This involves:services work. This involves:  Looking at services from the wayLooking at services from the way the patientthe patient receives themreceives them  Planning the pathway that a patient takes from start toPlanning the pathway that a patient takes from start to finish to see how it could be made easier & swifterfinish to see how it could be made easier & swifter  Best, modern clinical practice is identified & decisionsBest, modern clinical practice is identified & decisions made about which professional should best carry outmade about which professional should best carry out which functionwhich function
    5. 5. NHS PlanNHS Plan Results:Results: Impact dramaticImpact dramatic Improved services for patientsImproved services for patients Improved productivityImproved productivity Task of caring for patients easier for staffTask of caring for patients easier for staff In many cases resources released toIn many cases resources released to spend on other servicesspend on other services
    6. 6. Care PathwaysCare Pathways www.nelh.nhs.uk/carepathways/www.nelh.nhs.uk/carepathways/ "People and perfect processes make a"People and perfect processes make a quality health service - a poor qualityquality health service - a poor quality service results from a badly designed andservice results from a badly designed and operated process, not from lazy oroperated process, not from lazy or incompetent health care workers" Johnincompetent health care workers" John Ovretviet, Health Service Quality, 1992.Ovretviet, Health Service Quality, 1992.
    7. 7. ICPs – what are they?ICPs – what are they? • A tool & a concept that embed guidelines,A tool & a concept that embed guidelines, protocols & locally agreed, evidence-protocols & locally agreed, evidence- based, patient-centred, best practice, intobased, patient-centred, best practice, into everyday use for the individual patient.everyday use for the individual patient. • ICPs record deviations from planned careICPs record deviations from planned care in the form of variancein the form of variance
    8. 8. ICPsICPs Aim to have:Aim to have: The right peopleThe right people Doing the right thingsDoing the right things In the right orderIn the right order At the right timeAt the right time In the right placeIn the right place With the right outcomeWith the right outcome All with attention to the patient experienceAll with attention to the patient experience
    9. 9. And to compare planned care withAnd to compare planned care with care actually givencare actually given
    10. 10. Heart Failure care/servicesHeart Failure care/services See HF current pathwaySee HF current pathway
    11. 11. Heart Failure care/servicesHeart Failure care/services See HF proposed pathwaySee HF proposed pathway
    12. 12. Proposed HF Project PlanProposed HF Project Plan (May 2004)(May 2004) Data collection on registersData collection on registers Validation of registersValidation of registers Use of technician for new diagnoses (?Use of technician for new diagnoses (? use private contractor to provide thisuse private contractor to provide this service)service) Develop pilot of locally based diagnosticDevelop pilot of locally based diagnostic clinic – GPwSI-led, including referralclinic – GPwSI-led, including referral
    13. 13. GPwSI-led serviceGPwSI-led service One-stop diagnostic clinic with the followingOne-stop diagnostic clinic with the following options:options: Confirm/refute diagnosisConfirm/refute diagnosis If HF, initiate treatmentIf HF, initiate treatment Formulate management planFormulate management plan Either refer back to patient’s own GPEither refer back to patient’s own GP Or continue follow-upOr continue follow-up Or urgent fast track referral to secondary careOr urgent fast track referral to secondary care for review by specialist/further investigationsfor review by specialist/further investigations
    14. 14. Other aspects to considerOther aspects to consider Develop the rest of the ICPDevelop the rest of the ICP Streamline ‘front end’ of the proposed pathwayStreamline ‘front end’ of the proposed pathway Patient/carer informationPatient/carer information Community-based team – skill mix?Community-based team – skill mix? Links to ongoing care and end-of-life options etcLinks to ongoing care and end-of-life options etc Education/trainingEducation/training Development and spread of care/serviceDevelopment and spread of care/service provision across the PCTprovision across the PCT

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