Anticipatory Care Planning: Time To Make It Happen - Early Intervention Using The Life curve Dr Sarah Mitchell (Programme Manager - AHP National Delivery Plan)

1. AHPs: Driving Quality and Transforming Care Across Scotland
Active and Independent Living Improvement Programme
Anticipatory Care, Early Intervention and Wellbeing
Anticipatory Planning Programme Board
Friday 21st
October 2016.

2. 1. What matters to YOU as an individual to keep you healthy, active and independent?
< 3000 responses
2. Thinking of what AHPs could do in Health and Social Care in the future what should we focus
on to make services the best they can be?
< 3000 responses
• Thinking of what AHPs could do in Health and Social Care in the future what should we?
< 2000 responses to Q3
AHP Strategic Vision – 2015 and beyond
Powerful Questions
2

3. VISION
“Allied Health Professionals will work in partnership with the people of Scotland to enable them to
live healthy, active and independent lives by supporting personal outcomes for health and wellbeing”
AMBITIONS
•AHPs promoting Health & Well Being and early intervention
•AHP Services are easily accessible
•All stakeholders are aware of AHP Services
•AHPs working in Partnership
•AHPs delivering excellence through research and innovation
•AHP Workforce equipped to contribute to future health and social care requirements of population
What matters to YOU as an individual to
keep you healthy, active and independent?
Thinking of what AHPs could do in Health
and Social Care in the future what should
we focus on to make services the best they
can be?
Thinking of what AHPs could do in Health
and Social Care in the future what should
we

4. Scottish Social Work Vision and Strategy 2020
Key Themes from Occupational Therapy Engagement Events 2016
• Leadership
– Local and National
• Workforce
– Effective Utilisation of Occupational Therapy Workforce
– Career Pathways
– Training and Development
• Service Quality and Performance
– Measuring Impact
– More effective use of staff for early intervention and rehabilitation
• Improving Use of Evidence
– Access to best practice
– Use of evidence based practice
– Opportunities to participate in research
• Promoting Public Understanding

5. AILIP Logic Model
Scoping Inputs Outputs OutcomesScoping Inputs Outputs Outcomes
Situation Ambitions Priorities Resources Activities Engagement Short -Term Medium-Term Long-Term
Health & Well-
being
Access
Awareness
Partnership
Working
Research &
Innovation
Workforce &
Practice
Transformation
Well Being
Children & Young
People
STARTING WELL
Vocational
Rehabilitation
LIVING WELL
Musculoskeletal
Programme
LIVING WELL
Falls & Frailty
AGEING WELL
Anticipatory Care
AGEING WELL
Dementia
LIVING WELL &
AGEING WELL
E-Health including
Operational
Measures /
Workforce Tool
TEAM
CHPO & Team
Programme
Director
(1 X WTE)
IA
(3 x WTE)
National
Leads
(? X WTE)
Partners/
Suppliers
ADSG
H&SC
Partnerships
Public
3rd
Sector
ISD
Centre of
Excellence for
Rehabilitation
Research
SAS
NES
HIS
NHS 24
Awareness
• Increase awareness across H&SC Partnerships and other
partners of AHP contribution to the National Outcomes
Access
•Utilise technology to support access and care allocation
•Ensure visible routes for people to access AHP services
•Simplify processes for inter AHP referrals across services
•Ensure timely access into services to promote early intervention.
•Provide flexible services to meet demands
Workforce & Practice Transformation
•Ensure optimum number of AHPs working in the right settings to
maximise impact
•Support staff development to ensure competent, skilled and
knowledgeable workforce
•Support AHP workforce to undertake the cultural transformational
change that will be required to drive the AHP contribution to support
the H&SC agenda
Research & Innovation
•Identify innovative ways of service deliver to provide better outcomes
for users
•Work with Partners to spread Innovation through technology to
transform AHP delivery
•Ensure R&D will underpin any service development where appropriate
•Develop partnerships between academic institutes and AHP services
Partnership Working
• Contribute to multiagency pathways
• Collaborate to enhance quality of care
• Develop and implement new integrated models of care and
support
Knowledge
Management
•Capture and
report learning
and outputs
from AILIP and
other National
Programmes
•Report impact
through AILIP
Measurement
Framework
•Communicate
AILIP through
Managed
Knowledge
Network
Stakeholders
Public
H&SCP
NHS Boards
Third Sector Care
providers
General Practise
teams
Community
Health Teams
Housing
Organisations
Local Authorities
Other
Improvement
Programmes
National Policy
makers
Universities /
Colleges (HEIs)
AHP Federation
International
Partners
Community
Planners
Improvement
Bodies
The
transformational
learning around
access will be
spread to all AHP
Services
AHPs will work in
partnership with the
people of Scotland
to enable them to
live healthy, active,
and independent
lives, by supporting
personal outcomes
for Health and Well
Being.
The ethos of Active
and Independent
Living will underpin
all community
development.
AssumptionsAssumptions
AILIP will have required
staff and financial
resources to deliver
act ivies
Monitoring and evaluationMonitoring and evaluation Available Work
Days, Team
Workload,
Budget Variance
H&SCP will have the will
and capacity to engage
with local AILIP
improvement activity
AILIP will have access to
and be able to influence
development of dataset
and E-Systems.
AILIP can capture local
learning that is relevant
and transferrable to
other H&SCP
AILIP will reach all
relevant officers in
H&SCP across Scotland
AILIP will have the
capacity to put learning
into practice.
Engagement
with: test H&SCP,
National Bodies,
Partners
Project Progress,
Risk & Issues,
Governance Actions
Diagnostic Support,
testing Support,
Evaluation Support,
Writing-up
Projects that
Demonstrate
improvements and
efficiencies
Learning Events,
Learning WebEx,
Learning Resources,
Local Support
Event Contributions,
Publications, Blogs,
Tweets
Engagement
Spread, Social
Media Reach,
Website Usage,
Inbound Info Req.
Scottish Government
no longer identifies
AHP contribution to
H&WB as a priority
Please refer to
Individual Work streams
for additional
assumptions
Please refer to
Individual Work streams
for additional Measures
External FactorsExternal Factors
Please refer to
Individual Work streams
for additional external
factors
Short Term
Outcome
Medium Term
Outcome
Long Term
Outcome
Resources agreed
and developed to
support self
management, early
intervention for
H&WB
The benefits of
technology to drive
self management,
early intervention
and H&WB will be
spread
Spread of multi-
agency partnership
working will be
accelerated to
support self
management, early
intervention for
H&WB.
Population will have
direct access to an
AHP where
appropriate
Population will have
access to once for
Scotland evidence
based resources to
support self
management, early
intervention for
H&WB
Population will
benefit from
technologies to
support self
management, early
intervention for
H&WB
Population will
benefit from multi-
agency pathways to
support their self
management, early
intervention for
H&WB.
Appropriately skilled
and developed
workforce is
contributing to the
health and care
needs of Scotland in
a cost efficient and
person centred way.
Health & Well Being (Physical & Psychological)
•Promote Health and Well Being
•Promote early interventions into AHP services for both physical and
mental health problems
•Produce evidence based self management information in a range of
formats
•Promote brief interventions to address both physical and mental
health problems
Testing of workforce
tool and
development of
staff to undertake
transformational
change
Workforce tool
influencing
requirements and
staff leading
transformational
change
Introduction of
Health & Well-Being
Outcomes
Increased Focus on
Personal Outcomes
Lack of Awareness of the
AHP contribution to H&SC
Long waits to access many
CYP & Adult AHP Services
High number of
population with
disabilities not in
employment
Aging Population living
with complex needs
utilising more resources
Underutilisation of
technology to drive
innovative practice
Increased Demand on
Health & Social Care
Services
Integration of Health &
Social Care
Increasing Challenges on
GP and Primary Care
Services
Health & Social Care
Workforce Challenges

6. AHP Active and Independent Living Improvement Programme
Priorities 2016-18
Well Being
• Promote a Personal Outcomes approach across all AHP services
• Enhance the role of good nutrition to support well being
• Enhance the communication environment to support wellbeing
• Promote physical activity to support well being
• Promote screening for early diagnosis and intervention
Children & Young People (CYP)
• Deliver on Ready to Act ambitions
• Undertake pilot projects relating to 5 ambitions with selected Health and
Social Care Partnerships
• Drive contribution to transformation change plans in Primary Care
• rive contribution to transformation change plans in Primary Care
Vocational Rehabilitation (VR)
• Identify Current State of VR in Scotland
• Align work to the Health, Disability & Employment project in SG
• Drive implementation of AHP Fit Note
• Enhance approaches to VR in all AHP services
• Drive contribution to transformation change plans in Primary Care
Musculoskeletal Programme (MSK)
• Utilising technology to support access and care allocation
• Enhance approaches to self management and well being
• Create efficient pathways across acute, community and 3rd sector
• Drive contribution to transformation change plans in Primary Care
Falls and Frailty
• Support full implementation of the Framework for Action 2016-20
• Enhance approaches to falls prevention and frailty
• Partner with HSCP to drive falls/frailty ambulance pathways
• Drive contribution to transformation change plans in Primary Care
Anticipatory Care (AC)
• Create Pathways to facilitate AC planning
• Support AHP workforce to have “good conversations”
• Undertake pilot projects to test AC approaches
• Drive contribution to transformation change plans in Primary Care
Dementia
• Deliver on AHP Connecting People Connecting Support Policy
• Increase awareness of contribution to living well with dementia
• Influence and integrate AHP contribution with national transformational
changes
• Drive contribution to transformation change plans in Primary Care
Operational Measures / Workforce Tool
• Interrogate available data from existing systems
• Align Operational Measures to National Data sets
• Full Role out of Operational Measures to all AHP Services
• Create an AHP workforce workload measurement tool

7. AILIP Measurement Plan: Core Measures
(Draft Mental Health Strategy measures)
Health and Wellbeing
• People accessing and reporting benefit of self management
• More people who have AHP interventions earlier on their
“Lifecurve”
Personal Outcomes
• People report improved quality of life and achieving what is
important to them
• More people have interventions based on “good conversations”
• People report improved choice and control over what matters
to them
Access
• People are accessing AHP services via “request for assistance”
• People referred via GP/GP Directed
Partnership Working
• People referred/signposted by AHPs to non health and social
care support
• More multiagency published pathways
Workforce
• AHP staff contributing to the Workforce Workload Measurement
Tool and AHP H+SC Workforce
• Partnership areas implementing Operational Measures
Research and Innovation
• AHP technology interventions/initiatives aligned to the Scottish
Centre for Telehealth and Telecare

8. Preparing Ahead…?
• What are the most difficult topics?
• Who will look after me when I’m older(42%)
• Where will I live if I can’t remain in my current home (34%)
• What kind of end of life care I want (46%)
• Are they important questions to ask?
• 80% of people over 65 years think so
• 80% of their relatives think so
“We need to talk about caring: dealing with difficult conversations” Independent Age July
2016

9. However……
• 60% of people over 65 years haven't had this conversation (delayers) and
• 30% aren't even planning to (deniers)
• 20% of relatives have actually had this conversation, despite
• 41% of people who thought their loved one had died well when their wishes
were formally recorded
• Independent Age recommendations include: better information, better
knowledge about options (including care homes) and addressing peoples’ denial.

10. Anticipatory Care – AHP role within AILIP
• Long term impact
• People will have knowledge, resources and confidence to plan their future
health and wellbeing
• AHP workforce will be confident in having outcomes focussed conversations
which help people plan for their future
• Activities include:
• Developing resilience and confidence
• Brokering support networks
• Personalised education/advice
• Personal outcomes approach embedded across AHP services
• Identification of partners for early intervention

11. Compressed functional decline orCompressed functional decline or
the Lifecurvethe Lifecurve
functional
cognitive
risk
care
connections
health
Time elapsed after joining the curve

12. Why individual-specific matters
“Effects of structured physical activity on prevention of major mobility disability in older adults” Marco Pahor et al 2014

13. Current activity
• Embedding a personal outcomes approach – exploratory Good Conversations
• Synergy with improvement methodology
• Partners include House of Care, Public Health, Care Inspectorate, NES, Living Well in
Communities, Primary Care, NMAHP research, Alliance Scotland
• Compressed functional decline – Lifecurve activity
• Map AHPs across Scotland – where are they intervening? At what stage on the Lifecurve?
• Forth Valley Test of Change– at the start of the curve – across NHS and Third
Sector
• Take a personal outcomes approach – what matters to you?
• Identify where the person is on their Lifecurve
• Identify where there is a falls risk
• Identify where a person may benefit from an Anticipatory Care Plan (at an earlier stage)

14. Thank you!
My contact details:
Susan Kelso, AHP Lead Early Intervention Scottish Government
Email: kelsosu@northlan.gcsx.gov.uk or susan.kelso@nhs.net
Phone: 0794 308 3735
Twitter: @susankelsoAHP