Download NHS HIGHLAND VISION: THE GENERIC MODEL OF CARE 7

NHS HIGHLAND VISION: THE GENERIC MODEL OF CARE
7 SEPTEMBER 2010
The Generic Model of Care will underpin the NHS Vision Statement to provide high
quality, effective and sustainable patient centred services appropriate to the needs of
patients in a consistent way across NHS Highland. ‘Better Health, Better Care and
Better Value’ will result in quality of care to every patient every time. The NHS
Highland Quality & Patient Framework will be the essential foundation stone. There
will be continuous improvement in quality of care and outcomes, with much more
emphasis on supporting patients and their carers to maintain and sustain their own
health. Where care is required, this will be provided as locally as possible and care
needs will be anticipated as much as possible and therefore more become planned.
Unplanned or emergency admissions will, in some cases, be regarded as a failure of
the system.
The actual model of delivering the health care element is not radically different from
the current existing traditional model, and is still based on the patient/health carer
relationship. Traditionally this was the doctor/patient relationship and more recently
expanded to the patient/health carer relationship. It is still fundamentally based on
the assessment of the patients’ condition, examination, investigation, diagnosis and
the provision of appropriate treatment and management.
The fundamental change will firstly be the great emphasis placed on the philosophy
of patient self care and responsibility.
Secondly, for those patients requiring care an explicit health management plan will
be developed and this will be readily available and accessible to all those involved in
care, including the patients and carers. Currently the scheduled and unscheduled
(emergency) care of patients significantly involves those patients with a pre-existing
known condition. The basis of the Model of Care will be a Long Term Condition Care
Management Plan, and for appropriate patients an Anticipatory Care Plan, with an
Alert system identified [ACPA].
Thirdly, the care provided will be based on the identified needs of the patients and
this care will follow agreed pathways of care.
The implementation will involve rollout of this concept across the whole of NHS
Highland and will have a radical effect. There are already innovative approaches to
healthcare across parts of NHS Highland and the role out of these will ensure that
these are applied to patients across the whole of Highland in a consistent fashion.
The Scottish Government Health Department Policy “Better Health, Better Care”
(2007) suggested that ‘health services have to change if they are to keep pace with
population trends, patient needs and medical advances’. Table 1 compares the
traditional view of care to the newly evolving approach to care.
Table 1.
Traditional View
Geared towards Acute Conditions
Hospital centred
Doctor Dependant
Episodic Care
Disjointed Care
Reactive Care
Patient as a Passive Recipient
Self Care Infrequent
Undervalued Carers
Low Tec
Evolving Model
Geared towards Long Term
Conditions
Embedded in Community
Team Based Approach
Continuous Care
Integrated/Holistic Care
Pro-active and Anticipatory Care
Patient as a Real Partner
Self Care Encouraged & Facilitated
Carers Supported as Partners
High Tec
The traditional Model of Care is provided by a number of distinct and discreet
Healthcare Providers in different sectors across the organisation, as identified in
Figure 1 below.
Figure 1: Sectors of Care.
While the patient appears at the centre of care, services have often been developed
to meet the needs of the service providers. Previously there has been little emphasis
placed on patient and/or care or self-care to maintain and develop health. There are
real boundaries and barriers between GP Practices, Community Health Services,
Contractor Services, Local Authority Care and the hospital based Specialist Services.
These traditional sectors have differences in training and expertise, objectives and
expectations, funding and management/accountability processes and care is
accessed differently. As there is no single and integrated IT system across the NHS,
effective communication is difficult. NHS Highland services do not easily translate
into a seamless Model of Care for the patient. The new proposed Model of Care
ensures that the barriers between the different sectors are removed and patients will
flow between different parts of an integrated system, as identified in Figure 2
overleaf.
Figure 2: The Generic Model of Care.
The approach is to reduce the barriers between the providers along the spectrum of
care, so that the patient experience is seamless and transition of care from one
sector to another is smooth, consistent and continuous.
Patient self-care
Community Based Care by different providers
Hospital Based Specialist and Tertiary Care
Patient Focussed Care will mean more emphasis on the patient and carer taking
responsibility for their own health and care, having more knowledge and support to
ensure that this happens. The ‘expert patient’ will understand their base line health
status and be more aware of when to seek or initiate appropriate increased
healthcare.
For the patient with an LTC or ongoing healthcare need, there will an Anticipatory
Care Plan [ACP] and an Anticipatory Care Plan Alert [ACPA], which will be available
to all involved in their care. These will identify the person’s base line condition and
disease status, what changes a patient can and should make, ascertains when to
seek additional advice and care, and what criteria may lead to accessing Specialist
Care in both the scheduled and unscheduled situation.
Care in the Community Setting is the next level of care provided in the local
setting. The providers of this care are the GP and Practice, Contractor Services
(including Dentists, Pharmacists, and Optometrists etc.), Community Health Services
(Nursing, Midwifery, AHPs) and Local Authority Services.
The concept of developing multidisciplinary working in the Extended Primary Care
Team, whether real of virtual, will facilitate seamless and integrated care. This care
will be provided in a range of settings within the home and community and the types
of care have been identified in Figure 2.
Care in the Specialist or Secondary/Tertiary Care Setting is also identified in
Figure 2 and more Specialist Care will be provided out of the traditional hospital
setting, within a more multidisciplinary local approach. A fundamental concept to
underpin the Generic Model of Care is the development of agreed Conditions
Specific Management Pathways, which will identify the:
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Natural history and progression of the disease or condition.
The role of patient self-care and management.
The role of health care professionals in supporting self-care and selfmanagement.
Method of assessment of the condition, current appropriate investigation,
diagnosis, management, treatment, maintenance, discharge and follow up,
throughout the spectrum of care for that condition.
Criteria for escalation and management of progressing and complex disease.
Aspects of Specialist Care.
Discharge planning.
Within the Generic Model of Care, there will be a number of ‘Modules of Care’ as
identified in Figure 3 below, which will be developed for different types of conditions
and care. Within these developed modules, the range and types of care and
management from patient’s self-care through to complex Specialist and Tertiary care
will be identified, so that the patient escalation along the care pathway is quite
explicit.
This will result in a clear Framework of Care for NHS Highland identifying what
patients are being treated for what conditions, by specified providers at each and
every location.
Figure 3: Modules of Care.
Figure 4: Triangle of Care
If the Triangle of Care for a Long Term Condition with Anticipatory Care needs is
considered, as identified in Figure 4, then a respiratory disease such as Chronic
Obstructive Airways Disease (know as COPD) or Asthma will clearly illustrate the
pathway. Guided by the Condition Specific Care Pathway, the patient experience for
COPD or Asthma would be as follows:
Patient Self Care would mean that the patient with or without their carer would have
a good knowledge and working expertise of their asthma or COPD. The disease and
progression would be articulated in the ACPA. The patient and carer would know
what their normal disease status would be in terms of i.e. general wellbeing, exercise
tolerance, sleep pattern, cough, wheeze, breathlessness, sputum production,
spirometry assessment and other various signs. Self assessment would be regularly
carried out and enable the patient to self monitor their progress. Coincidentally these
assessments would be relayed to the local LTC carer, usually a LTC trained nurse,
who would monitor trends over time, the frequency of monitoring being dependant on
the severity of the condition. An ACPA would have been agreed and baseline care
documented, and also what patient treatment should change if the condition
deteriorated slightly. If the assessments indicated a significant deterioration either
the patient would manage as previously agreed, with augmented treatment such as
antibiotic therapy, steroid therapy or oxygen. The frequency of the self reported
assessment would be increased and early intervention would result. The LTC Local
Nurse would be aware of the disease deterioration and would increase support either
by indirect contact (telephone/VC) or a direct patient face-to-face review. The ACPA
would have identified trigger alerts for the escalation of care and access to
augmented Primary or Secondary Care Services, as appropriate.
If resolution of the episode of disease deterioration did not occur, then the ACPA
would detail what subsequent management or treatment should occur and a review
could take place either by the Primary Healthcare Team or a Specialist. This review
could take place by a Specialist in consultation from a distance by telephone or VC,
in conjunction with the LTC Local Nurse or the Primary Health Team. Subsequently
if the episode of care deteriorated significantly, then the patient could be seen by a
Specialist in a virtual community ward, at an outpatient clinic or as an inpatient within
the hospital, and this would follow the specific criteria laid out in the ACPA. With this
system, the Specialist will have had access to the deteriorating episode of care with
all the assessments and subsequent changes in management documented, and
therefore Anticipatory Care would ensue. The emergency consultation or admission
would be averted and hopefully any admission relatively well planned, along the lines
identified within the ACPA. Appropriate care would have been instigated at an early
stage following early assessment and alerts. All details of agreed care will be
included such as DNAR, palliation and the discharge planning process will already
have been discussed and documented, and therefore if the patient is admitted to
hospital, the planned discharge process will result in a more effective discharge
resulting in shorter lengths of stay and improved continuity of care within the
community setting.
Pilots of this process have already been implemented such as within Argyll & Bute for
patients with COPD and the Nairn Long Term Conditions Project. These projects
have been evaluated and have shown an increased quality of care, reduced
emergency admissions, a shorter length of stay, a more efficient discharge planning
process, and the patients have been able to be maintained appropriately within the
community setting for a longer time period.
The Condition Specific Care Pathway would be developed identifying the natural
history of the disease, how to manage deterioration of that episode across the
escalating pathway of care in terms of assessment, diagnosis, treatment, referral and
maintenance. This modular approach is therefore applicable to most types of care.
This Model of Care is not in itself a radical change, but the implications imply:
1. The needs of patients will be responded to in a consistent and holistic fashion, as
opposed to being influenced by the wants and demands of patients and staff.
2. Services will be re-configured and re-designed to meet the needs of patients as
quickly and locally as possible, but the implementation will be consistent across
NHS Highland.
3. Care will be provided by agreed pathways of care, so that care will be consistent
across NHS Highland, with duplication and inefficiencies avoided and a reduction
in any identified variation.
4. Outcomes of care will be robustly monitored to ensure compliance and
accountability to the care pathways and that high quality of care is being provided.
5. There will be an organisational consensus approach to care management by all
involved partners including the patient, health care, local authority, voluntary
sector and all other stakeholders.
6. Health carers will be required to adapt to new and innovative ways of working
across traditional boundaries of care to ensure a seamless, integrated approach
as locally provided as possible.
7. Technologies will support this shift in care.
8. Using the agreed care pathways, criteria for referral and an increased day
care/day case approach will result in a requirement for fewer beds in different
locations in NHS Highland.
9. Implementation will be developed across the whole of NHS Highland, so that
everyone will know what care will be delivered to which patients, by whom, where
and the point of access to care will be clear. This will result in a clearly identified
clinical framework.
10. Implementation will be lead by both clinicians and patients, for clinicians and
patients. The Board will establish a Clinical Board to guide this.
What Developments Are Now Required:
1. Fully develop the concept of Long Term Condition Management as a fundamental
cornerstone of providing care in NHS Highland.
2. Extend Anticipatory Care Plan and Alerts (ACPA) to cover all Long Term
Conditions and patients with ongoing healthcare needs, and perhaps consider for
all those patients in the over 75 year old age group.
3. Develop agreed Integrated Pathways of Care and Management for common
conditions.
4. Develop conditions specific referral criteria and a Triage Referral Management
System.
5. Build a rehabilitation approach and capacity into services.
6. Develop real integrated and multidisciplinary Extended Primary Healthcare
Teams including all partners in care.
7. Implement robust audit, monitoring and clinical governance of all care provision
throughout NHS Highland.
8. Develop integrated IT Systems with easy access to all involved in care to provide
a comprehensive and timely common record.
9. Training of locally based generic staff by more specialist experts to ensure
appropriate skills and competence.
10. Staff working practices will be different as there will be fewer direct patient
contacts, more generic training for staff, and an increase in multidisciplinary joint
care sessions, as well as an increased utilisation of tele/eHealth, especially for
consultation and advice. This will inevitably impact on the working practices of all
staff and have an effect on the job planning process for all staff.