A4 - Community Practice
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Preparing for the future ‘Towards 2026’: A new community service model at Mary Potter Hospice Teresa Read and Tanya Loveard
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A4 - Community Practice
- 1. Preparing for the Future ‘Towards 2026’: A new Community Service model at Mary Potter Hospice Teresa Read, Enhanced Community Services Project Manager Tanya Loveard, Allied Health Lead
- 2. Objectives of this session • To share planning and development of a new community service model • To reflect on the role of leadership • To outline the key processes critical to the project • To share achievements and challenges
- 3. “A Model of Care.... broadly defines the way health services are delivered. It outlines best practice care and services for a person or population group or patient cohort as they progress through the stages of a condition, injury or event. It aims to ensure people get the right care, at the right time, by the right team and in the right place” (Agency for Clinical Innovation, NSW 2013)
- 4. National Issues Regional issues • Palliative care managed clinical network (HWNZ) • Central palliative care network • 3DHB • Specialist service specifications for palliative care (Ministry of Health 2014) • Resource and Capability Framework (Ministry of Health 2012) • End of life care Working Party (Palliative Care Council 2014) • Population profiles and projected palliative care needs by DHB (Palliative Care Council 2014)
- 5. Referrals to Mary Potter Hospice
- 6. Caseloads
- 7. Falling through the cracks • Navigating across providers • Repeating your story • Referral delays • Information • Fragmentation in care • Who do I go to? • What do I do at the weekend? • How do services communicate and update each other?
- 8. Death data
- 9. and...understand changing ffaammiillyy ssttrruuccttuurreess MMuullttii--ggeenneerraattiioonnaall ffaammiilliieess aanndd tthhee ggrroowwiinngg rroollee ooff ggrraannddppaarreennttss
- 10. Strategic Plan 2011-2015 Education & Training Enhanced Community Services Fit for purpose Facilities Strategic Drivers Grow our service leadership and reputation as a Centre of Excellence Grow People, Partnerships and Community Capability Grow our Operational Sustainability and Capacity
- 11. Enhanced Community Service Model • Enhance ‘Hospice in the Home’ service and increase afterhours access • Build improved community partnership model
- 12. Mary Potter Hospice Needs Assessment • Time and motion study • Workshops with teams • Conversations • Literature review • Visits • Process mapping Patient journey • Learning from complaints 2012
- 13. Process Mapping patient journey •improved standardisation •teams accept referrals •triage patients •needs assessment tools •coordination and flexibility of services •electronic patient management system 2012
- 14. Time and motion study 2012 6000 5000 4000 3000 2000 1000 0 M i n u t e s PCC 's - Time Spent in Each Category Time and Motion Study Category Wel PCC 1 Wel PCC 2 Por PCC 1 Por PCC 2 Por PCC 3 Kap PCC 1
- 15. Enhanced Community Services Business Case 2013 (2014) • Increased community resource PCC • Nurse Practitioner candidate role • Project management roles (12 months) • Enhanced Community Service Project Manager (0.3 FTE) • Day Hospice and Allied Health Lead (0.3FTE) 2013
- 16. Leadership of project • Project Sponsor • Project Lead • Project Team • Reference Group • Team Leaders Forum • Leadership Programme • Secondments for staff • Nurse Practitioner • PDRP • Allied Health Leadership Model 2013
- 17. Allied Health Leadership Model Maori Service Plan Strengthening Medical structure Consumer Engagement Practice Sharing Service Model Caseload Management Day Hospice Pacific Service Plan
- 18. Strengthen partnerships • Shared practice roles • Shared records/Palcare • Day Hospice pilot • Triage and needs assessment roles • Carers programme • Community Volunteer pilot • Ambulance plans • Patient flow meetings with external partners • Managed Clinical Network proposal • Healing grief bereavement support group for Maori 2013
- 19. Fact finding mission 2013
- 21. 2014 Service Update Report •Summarised intent of project and proposed changes Tool to consult and engage with stakeholders
- 22. Enhanced Community Service Model Workstream development: 1. Community Service design 2. Day Hospice Model 3. Community Volunteer Plan 4. Community Engagement 5. Workforce capability 2014
- 23. What would success look like? 2014
- 24. Literature review findings and Fact finding Key themes across all: • Support rehabilitative, educational and psychosocial approach • Day Hospice expansion • Multidisciplinary • Patient and family experience • Service integration • Community hubs – ‘Hospice in the neighbourhood’ 2014
- 27. Consumer engagement • Current Consumer Engagement study aims to explore patient and carer experience of inpatient services in particular relation to care of people living with dementia. • This framework will be used further to validate our proposed future model of care and pilot a process of seeking on-going consumer feedback. 2014
- 28. Challenges • Pace of change • Time • Communication • Workforce adapting to change • Internal/external relationships • Information & communication technology 2014
- 29. Achievements Robust leadership and teamwork to bring staff with us • Staff satisfaction survey 2014 – • 12% increase in 2012 satisfaction score to 73% • 100% satisfaction in ‘change management’ – Clinical Services Team • Workforce professional achievements • External EQUIP accreditation results: 19 EA and 1 OA awards • CCDHB Leadership award and a Quality award • Leadership in progression of Managed Clinical Network
- 31. Strategic Plan Implementation Timeline
- 32. Summary We have : • shared the planning and development of an enhanced community service model • reflected on the role of good leadership • outlined the key processes critical to the project • Shared the achievements and challenges to date
- 33. Preparing for the future to ensure people: get the right care, at the right time, by the right team and in the right place
- 34. References • Agency for Clinical Innovation, New South Wales (2013) Framework for the State wide Model for Palliative and End of Life Care Service Provision. Agency for Clinical Innovation 2013. • Abel J, Walter T, Carey L, Rosenberg J, Noonan K, Horsfall D, Leonard R, Rumbold B, Morris D (2012) Circles of care: should community development redefine the practice of palliative care? BMJ Supportive Palliative Care • Angelo J, Egan R, Reid K (2013) Essential knowledge for family caregivers: a qualitative study. International Journal of Palliative Nursing; Aug 2013, Vol. 19 Issue 8, p383 • Davidson P, Hickman EH, Phillips J, Graham B (2006) Beyond the Rhetoric:What Do We Mean By a "Model of Care". Australian Journal of Advanced Nursing, 2006. 23(3): p. 47-55. • Health Foundation (2013). Improving patient flow: how two trusts focused on flow to improve the quality of care and use available capacity effectively. London: Health Foundation. • Help the Hospices Commission in to the Future of Hospice Care (2013) Working towards a hospice workforce that is fit for the future. Oct 2013
- 35. References • Help the Hospices Commission (2012) Future needs and preferences for hospice care: challenges and opportunities for hospices: A working paper of the Commission into the future of Hospice Care. • McIlfatrick S et al (2013) Public awareness and attitudes toward palliative care in Northern Ireland. BMC Palliat Care. 2013; 12: 34. • Paget A, Wood C (2013) Ways and Means: ‘Peoples final journey must be one of their choosing’. Demos • Statistics New Zealand (2010) Mortality and demographic data • The Kings Fund (2014) Community Services: How they can transform care. The Kings Fund 2014. • Tan H, O’Connor M, Wearne H and Howard T (2011) The evaluation of a triage tool for a community palliative care service provider. Journal of Palliative Care 28:3.
- 36. Contact us Teresa Read teresa.read@marypotter.org.nz Tanya Loveard Tanya.loveard@marypotter.org.nz
Editor's Notes
- We are delighted to be here today to share with you the work we have been doing during the last two years enhancing our community model of care. My name is .... And we are....
- The objectives of the session are:... We acknowledge that many hospices are reviewing services in a similar way and we hope that this presentation will prompt further discussion – perhaps in questions and answers – about Hospice’s views and approaches on the key essential elements required to build sustainability of services for the future.
- So going back to the title ‘enhanced community service model’ - what is a model of care? There are actually limited definitions of models of care within the literature. Davidson defined model of care as …….. (Slide) During Maori language week this year, we launched our proverb whakatauaki ‘whetu i te rangi’ translated as the ‘stars in the sky’. According to Maori mythology, stars are an enduring spiritual connection to whanau that have died. As the stars guided the great Maori navigators to Aotearoa, Mary Potter Hospice supports and guides our patients and whanau on their journeys. Each patient too, is like a star, guiding us in our work.
- We also have key national and regional policies and projects that influence our work and will continue to do so. So whatever we do, we need to take this into the context. Regionally, it is great to see the Managed Clinical Network up and running, bringing all regional PC stakeholders together to identify key areas to focus on collaboratively. This includes identifying the key essential elements necessary that will really make a difference to increasing access and efficiencies in services driving up the quality of care.
- Our data shows an increase of referrals by 26% from 4 years ago – 581 patients to 739 patients per annum. Doing more with less... However, during this time, our community service has more or less stayed the same. We currently do not have the service flexibility to meet the needs of all of our community
- Not all referrals are accepted. Our caseloads have increased. We have seen a 17% increase in number of patients, 0% increase in funding, and as you all know, increasing complexity.
- And what about, patients and families? Often it means up to seven providers involved in their care. That is tough. Imagine, going to seven different supermarkets for your weekly shopping each with different layouts and systems? Not easy.... Or you do your online shop – plan ahead – and then it doesn’t arrive. No school lunches! We are healthy... but those who are sick, those most in need, are let down – especially out of hours. Dying doesn’t stop over a long weekend!
- We have looked at death data and identified significant gaps (Mortality NZ data). We know from the research that approximately 75% of all deaths follows an anticipated course and that palliative care can add value. The most recent published data from Statistics NZ (2010), states that there were 1554 deaths in the CCDHB region, of which 30% accessed Hospice services and of these, 14% patients died in the inpatient unit. What quality of death did the remaining 1005 people in the region have? What is our role as a specialist provider to support that? We don’t know exactly how many of these deaths require SPC and how much we are underserving the need. We are hoping Heather Macleod will be able to tell us the answer to that soon. This year, we delivered training courses and workshops across 34 ARC facilities and across primary care (59 courses attended by 732 external participants this year). I will briefly tell you in a couple of slides time what we are doing in education and training to address future needs (Agency for Clinical Innovation, New South Wales (2013) Framework for the Statewide Model for Palliative and End of Life Care Service Provision. Agency for Clinical Innovation 2013. )
- Our world is changing…. and family structures are changing. This slide presented by Heather Richardson from HTH at Hospice NZ breakfast teleconference earlier this year. Increased dependents and less informal carers/support networks. In CCDHB, over the next 20 years, the population aged over 65 will increase by 78%, with the 85+ age group doubling in size. People’s need for services is growing faster than funding, meaning that we have to innovate and transform the way we deliver high quality services within the resources available.
- In 2011 the Mary Potter Hospice Business Case and needs assessment outlined the approach required to create a sustainable future for the Hospice. It highlighted all the complexities mentioned. These key drivers and 3 strategic projects aim to strengthen the Hospice as a valued and efficient service provider to meet the increasing level of demand, whilst maintaining high quality of care. The education and training review highlights the need to develop education services for patients and carers, build relationships with primary care and raise public awareness of palliative care through increased community engagement. We will elaborate on the ECS in next few slides Fit for purpose facilities are required to enable us to evolve to meet future need, improving Hospice spaces towards the development of a range of Day Hospice options together with the long-term objective of creating one community ‘hub’ with flexible working spaces and community services.
- So these are the aims of the ECS project as outlined by the business case. A recent report published by Help the Hospices, validates this urging Hospices to make broader shifts in how care is delivered in the future including a concentrated shift towards community-based care and away from hospitals being the focus care. However, like any project, as we worked with the widerteams, acknowledging emerging outcomes as work/project progress informed by teams
- We viewed a needs assessment as an essential part of the strategy in order to accurately determine gaps in services (what is and what isn’t working). We undertook a time and motion study with community teams exploring gaps in existing community services and opportunities to improve workforce systems – will share this in next slide Talking up the project – through meetings etc Engaging with staff also energised the staff involved, gave them opportunities to express their views and raised awareness creating discussions and ideas.
- We undertook processing mapping of the patient journey with clinical teams - making sense of systems and processes at every level from access/entry to discharge from services. This highlighted the areas where our systems or processes were letting us down. It emphasised the opportunity we had to clarify referral and discharge criteria, work smarter and more efficiently through mobile technology to enhance the coordination of services. We need to make our systems for capturing and processing data more workable and user friendly
- Palliative Care Coordinator Business case Increased Palliative Care Coordinators 1.5 FTE in Community to free up Team Leader time to triage The PCC surveys and data collection was during the period of March to April 2012 Overall the PCC’s spent 50% of their weekly workload managing clinical activities, 15% of their time documenting in PalCare, and 8% of time travelling as illustrated in Graph 5. Time spent with education activities was 15% but this was skewed towards one PCC attending a course during this survey period. There was some variability within key clinical sub-categories (Appendix B) across the PCC group with 58% of time on average was spent with patient visits. The PCC patient visits ranged from 35 minutes to 60 minutes in duration with an average visit time of 45 minutes. A first patient assessment took longer on average at 75 minutes (range 30 – 95 minutes) with follow up symptom management visits taking less time on average at 35 minutes (range 15 – 60 minutes). Patient and family phone calls ranged from 5 minutes to 20 minutes with an average time of 11 minutes Over the study period, the PCC’s spent on average one hour per day utilising PalCare which made up about 15% of their workload
- A key part of project was having the resources to free up Team Leader time to triage and manage staff and project work supported by project managers.
- A key part of project was having the resources Also building capacity in teams – this was recognised through the development of the Organisational Development Strategy. The first stage of this strategy is developing a leadership programme for staff where 20 middle managers (20) over 6 months - action learning ADD Professional development recognition programme (PDRP) programme building capacity in team Allied Health career progression framework with DHB
- These workshops with clinical teams created a common and agreed approach to future best practice. Out of the workshops with teams, we identified the 8 key projects to move forward with. The results align with the literature and informed the design of the enhanced service model. The Day Hospice programme is a key work stream and critical to building an improved community partnership. Our review of the literature indicates that Day Hospice services are changing and offering more rehabilitation, therapeutic and social models of care in addition to the traditional creative therapies
- Change has been incremental - bringing the teams with us and focusing on strengthening partnerships internally and externally. We have established the look and feel of a new service model by piloting small incremental changes and testing new service options Our IPU nurses are covering leave in community The district nurses and HPCT have access to Palcare and we plan to use schedular The literature tells us that up to 30% of hospital admissions could have been avoided if alternative forms of care had been available or if care had been managed better in the period leading up to the admission. So through more proactive planning and support in the community, we hope to decrease the need for acute services. Health Foundation (2013). Improving patient flow: how two trusts focused on flow to improve the quality of care and use available capacity effectively. London: Health Foundation.
- we looked at best practice from across the world visiting leading Hospice providers in the UK, Ireland, Australia and New Zealand and attending international palliative care conferences. A number of models of care were reviewed from different countries – these exercises were hugely beneficial to the project. Key learnings included Clinical and organisational leadership critical Shared electronic records and electronic systems that talk to each other First contact assessment one point of entry team reconfiguration Don't need to provide whole service - assess for service offering Community engagement - building compassionate communities Day hospice building on traditional models to wellbeing holistic models. Volunteering critical – involved in direct care, ACP, bereavement, neighbourhood volunteering, fundraising
- Tanya starts
- Summarised needs assessment and key findings Proposed key elements of enhanced community services model Tool to consult and engage with stakeholders
- Key lead for each workstream, project plan, TOR, MDT reps and set meetings usually linked to existing neetings eg TLF Weekly meetings between project leads and managers and monthly reports (is Ria project sponsor). Research indicates that the public’s understanding of palliative care is varied and for many people palliative care remains synonymous with death, dying or having cancer. Low levels of understanding highlight the need to ensure that services use a public health approach to palliative care in order to eradicate social taboos and ensure such services are sought out when required. McIlfatrick S et al (2013) Public awareness and attitudes toward palliative care in Northern Ireland. BMC Palliat Care. 2013; 12: 34.
- The King's Fund report, endorsed by HTH, published 2014 calls for a simplification of community services and the removal of unnecessary complexity and suggests that services need to be capable of a very rapid response and to work with hospitals to speed up discharge and to use triage tools to assist prioritisation and equity of service delivery. The Kings Fund (2014) Community Services: How they can transform care. The Kings Fund 2014. Tan H, OConnor M, Wearne H and Howard T (2011) The evaluation of a triage tool for a community palliative care service provider. Journal of Palliative Care 28:3.
- As mentioned by Teresa previously, we looked at best practice from across the world and we also undertook an extensive review of the literature investigating palliative care service models across the globe. NICE Angelo (2013) suggests that terminal home care is possible through family caregiver support, education and empowerment. Nurse led clinics and patient/whanau education MDT input Looking at use of tools and methods for evaluating services eg SKIPP, consumer interviews (which I will talk about later) And also increased engagement with consumers Service integration – increased collaboration with health partners – improved communication and joint planning International literature and practice supports the need for community hubs
- We laid out our roadmap reflecting our values, key workstreams and options for all stakeholders and circulated it widely.
- The preferred new model of care is not ‘change for change sake’, it responds to the need for improvement in the way people access hospice care and the services available to them. The Service model is not revolutionary but rather evolutionary. We will build on the existing foundations and concepts of team work and community participation. The redesign builds on what currently works well, and changes area that need improving. The transformation of community services and the proposed new model of care will change the pattern of care provided under the Hospice services shifting care closer to home. It is important to recognise that the model of care which includes the service design, day hospice, workforce and systems and community engagement is underpinned by the key elements of facilities, education and information technology.
- We recognised the importance of including the consumer voice in our project. The reality of end of life care is complex always unique to each individual. It is important that we develop support which begins with people’s personal experiences and ask “what would improve that?”. Paget A, Wood C (2013) Ways and Means: ‘Peoples final journey must be one of their choosing’. Demos
- Break and accelerator. Stopping and listening to anxieties, regrouping, reflecting and continuing. Things have taken longer than we thought – but that is a good thing. Important to test and work with teams developing new processes and systems. Often achieved through pilots. Newsletters, meeting agendas, networks Workforce: new roles, adapting to working in a more flexible manner but also in terms of care delivery working in a more consultative way. Our teams are working really hard with increased pressures from across the board. Relationships – linking internally through project membership and externally through MCN, liaising with stakeholders seeking to understand community perceptions. Development of website has been slower than expected due to need to upgrade the underlying platforms
- Pace important – accelerating and brakes Working relationships have improved as part of the change process. 12% increase in 2012 staff satisfaction score to 73% 100% satisfaction in change management CST 70% staff surveyed believe changes have improved services This validates the culture of learning and quality improvement at Mary Potter Hospice . The score achieved puts Mary Potter’s satisfaction score above the all-hospice benchmark. During 2013/2014, clinical staff authored 9 research publications in national and international journals, delivered 8 conference presentations and 9 poster presentations at national and international conferences. 52% nursing staff are on CCDHB PDRP and post grad EQUIP 4 – recognition though ‘outstanding’ award for ‘quality improvement’ and 19 extensive achievement awards Quality award for supporting quality improvement for quality programme manager MPH led workshops, development and securement of MCN proposal funding
- The preferred new model of care is not ‘change for change sake’, it responds to the need for improvement in the way people access hospice care and the services available to them. The redesign of the hospice model of care builds on what currently works well, and changes area that need improving. From the evidence to date, we have outlined our approach to increasingly establishing ourselves as a strong community based hub with increased outpatient, drop in and day care facilities. (point to slide) This includes Day Hospice, extension of community services, community volunteers and mobile technology. Moving toward 2016 and Hospice as a hub. As said before, a population health approach to palliative care is the most under-developed across most services. Yet, it is the approach that has the most potential to enhance the quality of life and sense of well being to the widest number of people in dying and in loss – getting out to the community, working with agencies and volunteers to build capacity and action!
- Change doesn’t happen overnight. It is important to bring the teams with you and have them inform the project. This takes time but ultimately leads to a more thorough review that is realistic, achievable and accepted by teams.
- To summarise, we have been on a journey to establish a new and more responsive model of care which will continue into the next three years. We are now taking on new responsibilities and operating in new ways to shape better hospice services for our local areas. In underpinning the move to a new model of care, where quality is at the heart of everything we do, we have a set of clear core priorities.
- At Mary Potter Hospice the Enhanced Community Service model is like the Koru ready to unfold. The ECS is.... ..Given new national policies in palliative care and the many challenges facing the palliative care sector there is a clear rationale for a redesign of Hospice services. The resulting model of care is one of consolidation that will build resilience in our services and communities and prepare the Hospice for more dynamic change in the longer- term.
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