Putting the Patient at the Heart of the Pathway


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An opportunity to hear how service redesign positively impacts on the patient experience and improves outcomes for both the patient and NHSScotland. Showcasing examples of changes to pathways of care in orthopaedics and community support for people with complex and chronic conditions.

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  • Need set of standard work instructions how to conduct IT projects. It is vital to have a record of the change and ensure that all effects of the change have been managed to ensure the required result of the project and this is addressed by Project Change Control process.
  • Putting the Patient at the Heart of the Pathway

    1. 1. Session 2.8: Putting the patient at the heart of the pathway
    2. 2. NHS Board Examples: Enhanced Recovery for patients undergoing hip and knee surgery – NHS Borders and Tayside Anticipatory Care Planning – NHS Forth Valley
    3. 3. Enhanced Recovery What is it? "What does enhanced recovery have to offer patients and the NHS? In simple terms it does two things. It improves quality of care by helping patients to get better sooner after major surgery. Secondly it reduces length of stay with obvious benefits to the NHS" Professor Sir Mike Richards Enhanced Recovery Partnership Programme Department of Health
    4. 4. Implementing Enhanced Recovery in Orthopaedics A Mehdi, A Todd, D Sommerville, J Antrobus, K Lakie, N Leary Borders General Hospital, Melrose
    5. 5. SUB HEADING Traditional Approaches
    6. 6. SUB HEADING Established Practices
    7. 7. Patient Journey - Pre-assessment - Admission - Perioperative Care - Length of Stay - Post – Discharge - Overall Satisfaction
    8. 8. Pre-assessment - Duplication of info - No clear guidelines for Arthroplasty patients - Variation - Patients passive partners
    9. 9. Admission - 100% day before surgery admission - Anaesthetic review at admission - 20% cancellation - Mixed nursing
    10. 10. Ward to Theatre - Pre -LEAN theatres 52 mins - Post – LEAN theatres 46 mins - Inconsistent skills of surgical assistant - 1 anaesthetist per list
    11. 11. Perioperative Care 100% Urinary catheterisation 100% HDU post op Medical Complications 0% mobilised day of surgery 40% of arthroplasty patients received a blood transfusion No standard DVT prophylaxis No local data collection/audit
    12. 12. <ul><li>Average length of stay for arthroplasty in the Borders – 7.7days (SAP Report 2009 </li></ul><ul><li>- Amongst longest LoS of all mainland Boards in Scotland </li></ul>Length of Stay
    13. 14. The Team
    14. 15. 13 th August 2010 VSM Kaizen Hamish McRitchie Rachel Bacon Ross Cameron Data Gathering Sponsor <ul><li>Kirk Lakie </li></ul><ul><li>Nigel Leary </li></ul><ul><li>Alison Todd </li></ul><ul><li>Trish Wintrup </li></ul><ul><li>Damon Somerville </li></ul><ul><li>Ali Mehdi </li></ul>Emergency pathway Referral processes ?Complex/orthogeriatric care Reduce length of stay to benchmark target Introduce new technique (Enhanced Recovery) Create capacity to meet WT targets and repatriate Lothian activity Elective orthopaedic patients Pre-assessment Operating process Post-op pathway to discharge Timeline Team Target Baseline In Process Metric Customer Metric: <ul><li>Reduce length of stay from 7.6 days – 5 days </li></ul><ul><li>Increase list capacity to 4 joints/day </li></ul>National MSK Audit MARCH 2010 Reduced length of stay Increased orthopaedic operations Improved patient experience measures From 28 th June Business Case Measurements Customer / Business Impact <ul><ul><li>Reduce length of stay for elective orthopaedic patients </li></ul></ul><ul><li>Provide sufficient beds to accommodate all orthopaedic activity </li></ul><ul><li>Increase orthopaedic throughput through theatres </li></ul><ul><li>Improve patient experience </li></ul><ul><li>Patients receiving elective major orthopaedic operations are having to stay longer in hospital than other areas. </li></ul><ul><li>It is not possible to fully utilise extra operating time in Theatres due to lack of available orthopaedic beds </li></ul>Goals Problem Statement In Scope Out of Scope <ul><li>Karen Haughey </li></ul><ul><li>Jackie Bell </li></ul><ul><li>Physio </li></ul><ul><li>OT </li></ul><ul><li>Wilma Cruickshank </li></ul><ul><li>More.. </li></ul>From20 th Sept – end Nov 2010 Orthopaedic Reduced Length of Stay, Project Charter V.1
    15. 16. - Draft pre-admission ICP - Management of patients expectations – CALEDONIAN TECH - Designated Anaesthetist at clinic Means of Change - Review of patient information booklet – Passport to Care - Anaesthetic assessment in pre-assessment clinic
    16. 17. Cascading
    17. 18. - Ward Nurse- direct bleep to theatre - Standardised anaesthetic protocol - Post op management guidelines implemented on Ward including ward doctors and HAN Means of Change
    18. 19. Pre-assessment Anaesthetic rotas revised to fit pre-assessment clinic Introduction of Hip and Knee school Patients proactive partners
    19. 20. Admission - 75% patients admitted on day of surgery
    20. 21. Cancellations
    21. 22. - 12 ring fenced beds - Dedicated arthroplasty ward nurses - Consistent pathway approach Ward to Theatre
    22. 23. - Positive patient feedback for transfer process - ERAS LEAN theatres 34mins Ward to Theatre - Over 90% of patients walk to theatre - Transfer to trolley in the Anaesthetic room - Single patient handover
    23. 24. Perioperative Care - 5% patients catheterised - 92% patients mobilised on day of surgery - 5% blood transfusions (Hb- 7.8-8.7) - VTE prophylaxis protocol - Audit database- opiate reduction- Excellent pain scores- 90%
    24. 25. 3 joints per day Before During Kaizen month Sustainability <ul><li>3 joints per day with no overruns </li></ul><ul><li>Additional capacity avoids need for sendaways </li></ul><ul><li>Pre Lean 1.8 joints per list </li></ul><ul><li>(7 joints per week) </li></ul><ul><li>Post Lean 2.4 joints per list </li></ul><ul><li>(9 joints per week) </li></ul><ul><li>ERAS Lean 3 - 4 joints per day comfortably with time to spare! </li></ul><ul><li>(12 joints per week) </li></ul><ul><li>Potential financial savings from sendaways </li></ul>Aim
    25. 26. Length of Stay Median Length of Stay- 3 days (Ave-3.9 days)
    26. 27. Lowest MLoS of all Boards in Scotland - 3 DAYS Length of Stay
    27. 28. Overall Satisfaction “ All the Medical and Nursing staff have been excellent. The new procedures being put in place with regard to patient recovery are also excellent. The literature given to me prior to admission is first class Mr T S (JEP) “ I had a hip replacement to my left hip 2 years ago and was in for 6 days. I found the treatment much improved. The pain relief much better and mobility much quicker. Treatment was excellent” Mrs E McK ( MMS ) “ Having experienced my first hip 17 months ago this 2 nd experience on “assisted recovery” has been marvellous. Being awake during the operation was (surprisingly!) a great experience I was not sick (as was last time) and it was so good to get up out of bed and mobilise on the same day. NO CATHETER this time was a bonus. All staff very communicative and attentive at all times. Going home after 2 days will also enhance my recovery as I know I will sleep better!” Mrs EC ( CHT )
    28. 29. Borders Enhanced Recovery Project Summary - Big Challenge - Better Preassessment - More activity/ less cancellations - Medicalisation /intervention almost eliminated - Excellent pain relief - MLoS 3 days - Better patient journey - Massive savings?
    29. 30. <ul><li>Further reduction of complications </li></ul><ul><li>Weekend Physio/OT </li></ul><ul><li>Anaesthetic Rota </li></ul><ul><li>Surgical support </li></ul><ul><li>Maximisation of capacity </li></ul><ul><li>Arthroplasty Practitioner </li></ul>Challenges
    30. 31. <ul><li>Sustainability </li></ul><ul><li>Saving to invest </li></ul><ul><li>Investment to save </li></ul><ul><li>Broadening the scope of enhanced recovery </li></ul>The Future
    31. 33. <ul><li>Matthew Checketts </li></ul><ul><li>Consultant Anaesthetist </li></ul><ul><li>NHS Tayside </li></ul>
    32. 34. Progress to date – ERP 2011 <ul><li>15 sites out of 22 have now developed ERP programmes and are testing them with a further two due to start in the summer </li></ul><ul><li>41% patients admitted on the day of surgery compared to 29% in 2010 </li></ul><ul><li>Length of stay in Scotland has fallen further with the median post operative day reducing from 5 to 4 days in less than one year </li></ul><ul><li>Urinary catheterisation has fallen from 35% to 26% </li></ul><ul><li>Blood transfusion has decreased especially following hip replacement from 14% to 11% </li></ul><ul><li>90% of patients are mobile within 24 hours of surgery with 36% of patients within an ERP up on the day of surgery </li></ul><ul><li>5% reduction in use of outpatient physiotherapy (84 New Patient Slots) </li></ul>
    33. 35. Anticipatory Care Planning What is it? Anticipatory care planning is applied to support those living with a long term condition to plan for an expected change in health or social status. It also incorporates health improvement and staying well. In practical terms it is about adopting a “thinking ahead” philosophy of care that allows practitioners and their teams to work with people and those close to them to set and achieve common goals that will ensure the right thing, being done at the right time by the right person(s) with the right outcome.
    34. 36. Stuart Cumming August 2011 Managing Complexity in the Community Anticipatory Care Planning
    35. 37. <ul><li>Benefits of Anticipatory Care Planning </li></ul><ul><li>Integrated working </li></ul><ul><li>Maintain independence </li></ul><ul><li>Support self management </li></ul><ul><li>Mainstream ACP principles </li></ul><ul><li>links with </li></ul><ul><li>Shifting the Balance </li></ul><ul><li>Long Term Conditions Collaborative </li></ul><ul><li>Quality Strategy </li></ul><ul><li>Reshaping Care for Older People </li></ul><ul><li>Change Fund </li></ul>Overview
    36. 38. Laura age 41 <ul><li>Rapidly progressive MS </li></ul><ul><li>Communication, airway, mobility, care and nutritional issues </li></ul><ul><li>Medication management and symptom control </li></ul><ul><li>Childcare </li></ul><ul><li>Carer Support </li></ul><ul><li>Home adaptations </li></ul><ul><li>Telehealth </li></ul><ul><li>24/7 care package </li></ul><ul><li>Primary Care Team </li></ul><ul><li>Complex Care Team </li></ul><ul><li>Local Authority </li></ul>“ Spending more…quality time with my children, family and friends”
    37. 39. The exception or the norm…?
    38. 40. <ul><li>Ageing population and increasing Long Term Condition prevalence </li></ul><ul><li>Increased emergency admissions in elderly (>80) </li></ul><ul><li>Last 20 yrs – x10 increase in elderly with >3 admissions/yr </li></ul><ul><li>Consequent extended stay and delayed discharge </li></ul><ul><li>Increasing number of short, “avoidable” stays </li></ul><ul><li>Not desirable or sustainable in long term </li></ul><ul><li>Need for anticipatory “thinking ahead” approach to ongoing care to enable independence and awareness of options </li></ul><ul><li>Need to recognise the capability of primary care </li></ul>
    39. 41. The Changing Picture of Long Term and Palliative Care Bill age 76 <ul><li>Primary Care team </li></ul><ul><li>At risk register </li></ul><ul><li>Practice meeting </li></ul><ul><li>Pharmacy </li></ul><ul><li>Community Nursing </li></ul><ul><li>Specialist Nurse </li></ul><ul><li>Macmillan Nurse </li></ul><ul><li>Hospice </li></ul><ul><li>Education and training </li></ul><ul><li>Self management/ </li></ul><ul><li>management plan </li></ul><ul><li>Carer support </li></ul><ul><li>Hand held ACP </li></ul><ul><li>Domiciliary oxygen and compressor </li></ul><ul><li>pO2 monitoring </li></ul><ul><li>Single shared assessment </li></ul><ul><li>OOH notes </li></ul><ul><li>- Preferred place of care </li></ul><ul><li>- Rescue medication </li></ul><ul><li>- Palliative Care Plan inc DNA CPR </li></ul>“ Working together…. understanding what’s going on ”
    40. 42. <ul><li>Doing the right thing for the right person at the right time with the right outcome – every time </li></ul><ul><ul><li>Improve communication and 24/7 partnership working </li></ul></ul><ul><ul><li>Need to involve patient and family as partners in care </li></ul></ul><ul><ul><li>Anticipatory rather than reactive approach </li></ul></ul><ul><ul><li>Helps co-ordinate and shift the balance of care </li></ul></ul><ul><ul><li>Workforce – education, training, communication, capacity, planning </li></ul></ul><ul><ul><li>Align organisational priorities and attitudes and recognise differences </li></ul></ul>“ Anticipatory Care Planning is a process of discussion between an individual and their care providers irrespective of discipline” (DOH 2007) or…
    41. 43. Shift the Balance in a considered way Not always straightforward but it can be done if planned
    42. 44. Kathleen age 92 <ul><li>Multiple LTCs </li></ul><ul><li>Fractured hip </li></ul><ul><li>Main Carer in full time employment </li></ul><ul><li>Wheelchair </li></ul><ul><li>Delayed discharge issues </li></ul><ul><li>Care Package </li></ul><ul><li>Nursing Care </li></ul><ul><li>GP </li></ul><ul><li>Pharmacy </li></ul><ul><li>Crossroads </li></ul><ul><li>MECS </li></ul><ul><li>Community support </li></ul>“ Being allowed home …. getting some of my independence back”
    43. 45. Who can benefit? Possible ACP Triggers <ul><li>Situation </li></ul><ul><li>Long term housebound </li></ul><ul><li>Complex care package or in receipt of respite care </li></ul><ul><li>Entry to care home* or community hospital </li></ul><ul><li>After discharge from unplanned admission </li></ul><ul><li>Frequent OOH contacts </li></ul><ul><li>Carer stress </li></ul><ul><li>Condition </li></ul><ul><li>Deteriorating long term condition </li></ul><ul><li>Requiring specialist nurse </li></ul><ul><li>Attendance at memory clinic </li></ul><ul><li>Placed on palliative care *, dementia, learning disability or mental health register </li></ul><ul><li>Clinical Assessment </li></ul><ul><li>SPARRA(?>50) </li></ul><ul><li>Polypharmacy </li></ul><ul><li>Falls assessment </li></ul><ul><li>Recognised as vulnerable </li></ul>
    44. 46. Integrated Community Based Care Rural North West Forth Valley Partnership <ul><li>Community based, multi agency approach to delivering integrated care </li></ul><ul><li>Aims </li></ul><ul><li>Reduce hospital admissions and length of stay </li></ul><ul><li>Quicker more local response </li></ul><ul><li>Improve transitions between phases of care </li></ul><ul><li>Shifting the balance of care through streamlining and localising current referral routes focus on crisis care, rehab and reablement </li></ul><ul><li>Improve involvement of carers / families / communities </li></ul>
    45. 47. <ul><li>Previous Service </li></ul><ul><li>Fragmented </li></ul><ul><li>Single agency </li></ul><ul><li>Multiple locations </li></ul><ul><li>Can delay discharge </li></ul><ul><li>- Not locally provided </li></ul>New Service Skill shifting & enhancement Co – location of MDT Joint agency training Joint management of MDT Community Nursing Team, GPs & Pharmacists Social Care, Care Management & Telecare Rehabilitation, Therapists & Podiatrists Health Improvement Mental Health Education Services & Housing PATIENT
    46. 48. Focus on Improving Communication <ul><li>People </li></ul><ul><li>Rapid response carers undertaking basic nursing and therapy tasks </li></ul><ul><li>Locally based joint agency centre </li></ul><ul><li>Links with care homes, rehab training, JIT, community transport, national park </li></ul><ul><li>Technology </li></ul><ul><li>Digital Memory Pens </li></ul><ul><li>Video-conferencing / Skype - reduce meeting time </li></ul><ul><li>Talking Medicine labels </li></ul><ul><li>Tele-health monitoring </li></ul><ul><li>MECS </li></ul>
    47. 49. <ul><li>Case Study 1 – Anne age 82 </li></ul><ul><li>“ Able to do more for myself” </li></ul><ul><li>Lives alone </li></ul><ul><li>Struggling with personal care, transfers and cooking </li></ul><ul><li>? Hospital admission </li></ul><ul><li>Rapid response started </li></ul><ul><li>Seen 4 times a day </li></ul><ul><li>Reducing with return to independence. Can now have a shower and dress, able to get out of bed without help </li></ul>Making differences
    48. 50. <ul><li>Complex Medical Condition </li></ul><ul><li>Referred because struggling at home due to infection – team due to start next day </li></ul><ul><li>Admitted overnight before seen </li></ul><ul><li>Liaised with fast track and once medically stable (2 days) returned home </li></ul><ul><li>Daily OT/PT input to rehab at home </li></ul><ul><li>Joint working with Reach FV clinical specialist physio and rehab consultant </li></ul><ul><li>Carers support 2 x day </li></ul>Case Study - Martin age 35 “ Getting out of hospital ASAP”
    49. 51. What the patients say… <ul><li>When I was ill, people of all different skills were there preferable to be at home beside your family, in your own surroundings....it would have taken a lot longer (to get home) if there hadn’t been something in place </li></ul><ul><li>But they didn’t want to let me out on my own – because I live on my own – without some kind of carer being around. I had a carer here that evening. …to meet me and check I was all right and that’s a very reassuring thing </li></ul><ul><li>It got him more mobile. Definitely helped a lot when coming back from hospital. The OT returned at end to see the goal was achieved </li></ul><ul><li>It was reassuring …especially at the beginning.. if things aren’t going right there’s someone there to help you </li></ul><ul><li>Having people to help me was a great help and eventually I said I really ought to be able to do this myself…but if you </li></ul><ul><li>wouldn’t mind being near the door just in case </li></ul>
    50. 52. <ul><li>Carers / Relatives Perspective </li></ul><ul><li>[without help] it would have been a struggle. Without it ..well my son / daughter…he’s working everyday … and you felt you were relying too much... certainly did appreciate the help </li></ul><ul><li>It’s so difficult if..[name] had to go into hospital and stay there. When he was in...with all the toing and froing.. I was just exhausted. When they (the team) started back up again I thought ‘phew!’ - a wee break - it’s very emotionally draining as well as the traveling </li></ul><ul><li>It’s reassuring from relatives point of view, but also from patient’s point of view </li></ul>
    51. 53. Value of Anticipatory Care Planning for patients identified using SPARRA data <ul><li>135 patients </li></ul><ul><li>26 practices </li></ul><ul><li>SPARRA score (40-60%) </li></ul><ul><li>SBAR tool </li></ul><ul><li>( S ituation, B ackground, A ssessment, R ecommendation) </li></ul><ul><li>ACP for 12 months with quarterly review </li></ul>
    52. 54. SPARRA Project Outcomes <ul><li>Emergency admissions (51%) </li></ul><ul><li>Bed days (39%) </li></ul><ul><li>Care Home admissions halved </li></ul><ul><li>Reduced GP contacts (14%) and OOH (18%) contact </li></ul><ul><li>A&E presentations (15%) </li></ul><ul><li>Increased involvement of the patient / carer / family in care plan </li></ul><ul><li>Key is joint working </li></ul>
    53. 55. Anticipatory Care Planning <ul><li>Patient Benefits </li></ul><ul><li>Better understanding of condition </li></ul><ul><li>Helps to set goals and enables self management </li></ul><ul><li>Discuss preferences, options and clarify legal issues </li></ul><ul><li>Enable working in partnership </li></ul><ul><li>Anticipate options if condition/situation deteriorates </li></ul><ul><li>System Benefits </li></ul><ul><li>Improved management of ‘at risk’ patients </li></ul><ul><li>Better joint working and communication </li></ul><ul><li>Helps to use services appropriately </li></ul><ul><li>Reduce hospital admissions </li></ul><ul><li>Avoidable emergency and OOH contacts </li></ul>
    54. 56. Other pieces of work….
    55. 57. Falls Pathways Polypharmacy Whole System Working - Patient journeys Facilitated Self Management Effective Information Sharing
    56. 58. Supporting People with Long Term Conditions to Self Manage The Self Care Toolkit My Support Plan
    57. 59. Self Management - the cultural change <ul><ul><li>Review what self management support is available </li></ul></ul><ul><ul><li>Make quality patient information better and more accessible </li></ul></ul><ul><ul><li>Improve health literacy </li></ul></ul><ul><ul><li>Remember carer support </li></ul></ul><ul><ul><li>Educate professionals in skills to support people to self manage </li></ul></ul><ul><ul><li>Develop a culture less reliant on specialist intervention </li></ul></ul>
    58. 60. Working Smarter with Electronic Communication GP /DN Consultation ECS / ePCS / KIS GP OOH Service Patient Electronic Clinical Record Hospice A+E, CAU SRI SAS
    59. 61. Make the exceptional the norm <ul><li>Lives in very rural area </li></ul><ul><li>Partner was her main carer and recently died </li></ul><ul><li>Family having to return to England after funeral </li></ul><ul><li>Team in place morning after funeral to support, assess long term needs and allow family to return home </li></ul><ul><li>Without this, possible need to offer residential / hospital care </li></ul><ul><li>Providing care and caring </li></ul>Mary - age 76 Good Anticipatory Care Planning
    60. 62. Thank you