1 Engaged, informed individuals & carers Commissioning Organisational & clinical processes...
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1 Engaged, informed individua ls & carers Commissioning Organisational & clinical processes Person- centred, coordinat ed care Health & care professiona ls committed to partnership working Plan Study Do Act The House of Care: The House of Care describes four key interdependent components that, if implemented together, will achieve patient centred, coordinated service for people living with long term conditions and their carers.
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Transcript of 1 Engaged, informed individuals & carers Commissioning Organisational & clinical processes...
1
Engaged, informed
individuals & carers
Commissioning
Organisational & clinical processes
Person-centred,
coordinated care
Health & care professionals committed to partnership
working
Plan
Study
Do
Act
The House of Care:
The House of Care describes four key interdependent components that, if implemented together, will achieve patient centred, coordinated service for people living with long term conditions and their carers.
Building the House – The House of Care Toolkit
• A framework to bring together all the relevant national guidance, published evidence, local case studies and information for patients and their carers.
• It includes information on what tools and resources are required to achieve person-centred coordinated care and how these can be effectively commissioned.
• Resources are arranged into the four key components of the House with summaries of the impact that could be achieved, based on current evidence and details about where to find additional information.
To Enter the House first chose your level:
NationalPersonal Local
Examples of local examples of good practice
that will inform the commissioning of services
at a local level .
Supporting for professionals, services
users and carers to work together to understand, plan and deliver person
centred coordinated care.
National and international guidance, evidence, tools
and resources that will enable the construction of the House of Care at the
next two levels.
Organisational and Clinical Processes
Person centred- coordinated care
Health and Care Professionals committed to partnership
working
• Integration• Culture • Workforce• Technology• Care Co-ordination• Care Planning
• Information and technology• Care Planning• Safety and Experience
Informed and engaged patients
and carers
• Self management• Information and T
echnology• Group and peer s
upport• Care Planning• Carers
Commissioning • Service User and Public Involvement• Contracting and procurement
• Needs Assessment and Planning• Joint commissioning of services • Metrics and Evaluation
• Care Planning• Tools and levers
Build my own house
Click on the links below for more information about
each component and use this to build your own house
• Guidelines, evidence and national audits
• Care Delivery
Enables individuals to make informed decisions which are right for them, and empower them to self-care for their long term conditions in partnership with health and care professionals. It relies on four key components, all of which must be present for the goal, person-centred coordinated care, to be realised
– Commissioning – which is not simply procurement but a system improvement process, the outcomes of each cycle informing the next one.
– Engaged, informed individuals and carers – enabling individuals to self-manage and know how to access the services they need when and where they need them.
– Organisational and clinical processes – structured around the needs of patients and carers using the best evidence available, co-designed with service users where possible.
– Health and care professionals working in partnership – listening, supporting, and collaborating for continuity of care. 5
Person centred- coordinated care
Back to house
Integration Ensuring care is designed and delivered around the needs of the individual.Integration is particularly important for people with complex care needs.Services should be joined-up to promote improved outcomes for individuals in need of health and social support, enabling them to live not just longer, but better lives.
Care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes
Back to house
Interdisciplinary working Professionals from different
organisations across health and social care and the voluntary sector working
closely together ensuring that care feels coordinated to people living with long term conditions and their carers.
Key Components • Single point of contact• Multi disciplinary team working • Professionals talk to each other• Services quick and responsive
people are promoted to stay independent and active
• Care developed around the individual and not the system
Care Transition
Ensuring a seamless transition for people with long term conditions between different care settings.
Key Components • Transition following discharge from
hospital • Transition related to changes in long
term care needs • Transition from children's to adult
services.
Health & care professionals committed to partnership
working
Interdisciplinary Working
Resources
Integrated care for patients and populations: Improving outcomes by working together - A report to the Department of Health and the NHS Future Forum, The Kings Fundhttp://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together
Integrated Care and Support Pioneers programme, NHS IQhttp://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions/integrated-care.aspx
Integrated Care – Better Care Fund – Local Government Associationhttp://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE
Integrated care value case toolkithttp://www.local.gov.uk/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4060433/ARTICLE
ICASE - Integrated Care Support and Exchange http://www.icase.org.uk/pg/dashboard
Kings Fund Integrated care: making it happenhttp://www.kingsfund.org.uk/projects/integrated-care-making-it-happen
Back to integration
Health & care professionals committed to partnership
working
Care Transition
Resources
Lost in transition, Moving young people between child and adult health services, Royal College of Nursinghttp://www.rcn.org.uk/__data/assets/pdf_file/0010/157879/003227_WEB.pdf
Transitions between children’s and adult’s health services, and the role of voluntary and community children’s sector, VSS POLICY BREIFINGhttp://www.ncb.org.uk/media/42225/transition_to_adult_services_vss_briefing.pdf
Transition, National Council for Palliative Carehttp://www.ncpc.org.uk/transitions
Coordinated transition between health and social care, NICEhttp://www.nice.org.uk/media/7C5/66/TranstionBetweenHealthAndSocialCareDraftScope.pdf
Back to integration
Health & care professionals committed to partnership
working
Culture
To promote an environment where people with long term conditions, their carers and professionals involved in their care have an equal relationship and a joint responsibility for managing their care. To ensure parity of esteem where physical health is valued equally with mental health.
Back to house
Promoting a partnership approach to care
To better involve patients in decisions about their
own healthto facilitate self-care.
Key Components • Developing equal
relationships between patients and professionals
• Sharing information to support patients to self-care
Clinical Champions and Professional SupportEffective leadership from professional bodies us key to embedding the type of culture change
that is needed.
Key Components • Supporting the
workforce to adjust to a new way of working
• Governance• Professional practice• Cultural relationships.
Health & care professionals committed to partnership
working
Parity of EsteemPeople with poor physical health are at higher risk of experiencing mental health problems and people with
poor mental health are more likely to have poor
physical health.Key Components
• Valuing mental health and physical health equally.
• Considering the physical impact of living with a mental health condition and the mental health impact of living with a long term condition
Promoting a partnership approach to care
Resources
Shared decision making, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/
Measuring Shared Decision Making A review of research evidence, NHS Right Carehttp://www.rightcare.nhs.uk/wp-content/uploads/2012/12/Measuring_Shared_Decision_Making_Dec12.pdf
Changing the culture: resources developed by AQuA, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/resources/aqua/
Back to culture
Health & care professionals committed to partnership
working
Clinical champions and professional support
Resources
Care Planning, Royal College of General Practitioners http://www.rcgp.org.uk/clinical-and-research/clinical-resources/care-planning.aspx
6 C’s Compassion in Practice, NHS England http://www.england.nhs.uk/nursingvision/
Association for Directors of Adult Social Serviceshttp://www.adass.org.uk/
Royal College of Nursing https://www.rcn.org.uk/
Back to culture
Health & care professionals committed to partnership
working
Parity of Esteem
Resources
Valuing mental health equally with physical health or “Parity of Esteem”, NHS Englandhttp://www.england.nhs.uk/ourwork/qual-clin-lead/pe/
Long-term conditions and mental health The cost of co-morbidities, The Kings Fundhttp://www.kingsfund.org.uk/publications/long-term-conditions-and-mental-health?gclid=CPCbxbyoxrwCFeXKtAodh0YA4g
Mental Health Partnershipshttp://mentalhealthpartnerships.com/
Back to culture
Health & care professionals committed to partnership
working
Workforce
Ensuring that the workforce is configured to support partnership working bothbetween different professional groups and between services users and professionalsproviding care. This will include considerations regarding integration of the workforce to provide a coordinated approach to people living with long term conditions andclarification of roles and responsibilities of professionals and opportunities fortraining.
Back to house
Integration
The long term conditions workforce should offer a seamless pathway of care to patients and carers. Effective workforce integration should be in place to achieve this.
Key Components • Joint training• Skill mix • Joint health and social care roles • Communication• Multi-disciplinary team working
Roles, responsibilities and training
Ensuring the workforce supporting people living with long term conditions are aware of the role they play and are
appropriately trained.
Key Components • Continuing professional
development • Person specifications• Training
Health & care professionals committed to partnership
working
Integration
Resources
Integrated care for patients and populations: Improving outcomes by working together - A report to the Department of Health and the NHS Future Forum, The Kings Fundhttp://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together
Integrated Care – Better Care Fund – Local Government Associationhttp://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE
Coordinated transition between health and social care, NICEhttp://www.nice.org.uk/media/7C5/66/TranstionBetweenHealthAndSocialCareDraftScope.pdf
Integrated Care and Support: Our Shared Commitmenthttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198748/DEFINITIVE_FINAL_VERSION_Integrated_Care_and_Support_-_Our_Shared_Commitment_2013-05-13.pdf
Back to workforce
Health & care professionals committed to partnership
working
Roles, responsibilities and training
Resources
Long Term Conditions, Skills for Health http://www.skillsforhealth.org.uk/service-area/long-term-conditions/
Delivering better services for people with long-term conditionsBuilding the house of care, Kings Fundhttp://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/delivering-better-services-for-people-with-long-term-conditions.pdf
Back to workforce
Health & care professionals committed to partnership
working
Information and Technology
Information systems and technology that facilitate equal relationshipsbetween people with long term conditions, their carers and professionals providing their care. This may be achieved through better access to informationor technology to allow patients to have a greater role in condition management.
Back to house
Shared information systems
Facilitating the sharing of information between different professional groups involved in the care of an individual to
improve the management of care. Sharing information will aim to ensure the
wider need for the individual are considered by all professionals involved in
their care.
Key Components • Joint care plans • Shared access or joint information
systems across health organisations and between health and social care
Patient Held Record
The patient is given a copy of the record to keep, and to take to health appointments, to help manage
healthcare tasks and communication. PHRs are formal and structured records that are given to patients to enable the
continuity and quality of care.
Key Components• Structured sections of patient and
healthcare information• Blank sections to enable patient note-
taking and healthcare staff notes
Health & care professionals committed to partnership
working
Shared Information Systems
Resources
Technical Approaches for Sharing Care Plans, NHS QIPP Workstreamhttp://www.connectingforhealth.nhs.uk/systemsandservices/qipp/library/careplans.pdf
Summary Care Record, Health and Social Care Information Centrehttp://systems.hscic.gov.uk/scr
Back to information and technology
Health & care professionals committed to partnership
working
Patient Held Record
Resources
Summary Care Records, NHS Choices http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/servicedescription.aspx
Enabling patients to access electronic health records Guidance for health professionals, Royal College of General Practitionershttp://www.rcgp.org.uk/clinical-and-research/practice-management-resources/health-informatics-group/~/media/Files/CIRC/Health%20Informatics%20Report.ashx
Patient record access: turning it on, sharing the learning, The Health Foundationhttp://www.health.org.uk/areas-of-work/programmes/closing-the-gap-through-changing-relationships/related-projects/patient-record-access/
Back to information and technology
Health & care professionals committed to partnership
working
Co-ordination of care
Supporting people to better understand the health and social care systemso that they can get the support they require when they need it.This can range from a person having a named professional as a first point ofcontact with the health system to a case manager responsible for coordinating the health and social care for people with multiple complex long term conditions.
Back to house
Case Management
A targeted, community-based and pro-active approach to care that
involves case-finding, assessment, care planning, and care co-ordination
accurate case-finding to ensure patients with highly complex and multiple conditions receive high-intensity
professional support.
Key Components: • Processes to identify those suitable
for case management are in place• Case managers have an appropriate
case load• Case managers are able to effectively
coordinate care
Care Co-ordination
Supporting individuals find their way around the, sometimes complex
services provided by health and social care.
Key Components • Care navigators • Directory of services • Identifying and assessing needs for
people living with long term conditions and their carers
• Ability to identify the most appropriate services for the individual
• Developing support plans
Health & care professionals committed to partnership
working
Case Management
Resources
Case Management, What it is and how it can best be implemented, The Kings Fundhttp://www.kingsfund.org.uk/sites/files/kf/Case-Management-paper-The-Kings-Fund-Paper-November-2011_0.pdf
Case management and community matrons for long term conditions, British Medical Journalhttp://www.bmj.com/content/329/7477/1251
Back to co-ordination of care
Health & care professionals committed to partnership
working
Care Co-ordination
Resources
Safer passage: how care navigators help improve mental health services, Health Services Journalhttp://www.hsj.co.uk/resource-centre/best-practice/local-integration-resources/safer-passage-how-care-navigators-help-improve-mental-health-services/5041420.article#
Co-ordinated care for people with complex chronic conditions, Kings Fundhttp://www.kingsfund.org.uk/projects/co-ordinated-care-people-complex-chronic-conditions
Care co-ordination through integrated health and social care teams, Kings Fundhttp://www.kingsfund.org.uk/projects/gp-commissioning/ten-priorities-for-commissioners/care-coordination
Back to co-ordination of care
Health & care professionals committed to partnership
working
Back to house
Care Planning
An interactive partnership between clinician and patient supporting self
management .
Key Components • Information should be given to the
patient prior to the appointment • During the appointment achievable
goals should be set in partnership.• Ongoing process • Capturing gaps between preferences
and care received and feeding back these preferences to inform future planning.
Care PlanningProfessionals need to recognise that the personal assets that patients (and their families) bring to the care planning process are as important as the clinical information in the medical record. They must ensure contacts people with long term conditions, their carers and have meet their physical, social and emotional wellbeing needs and best support them to manage their condition. Effective care planning requires both patients and professionals to adequately prepared in advance and are clear about the purpose of the care planning process.
Health & care professionals committed to partnership
working
Motivational support
Facilitating healthy, sustainable behaviour change by supporting people living with
long term conditions to take a more active role in their own care. To do this, people
require skilled support and motivation from their clinicians.Key Components
• Motivational interviewing techniques • Health coaching • Using a guiding style to engage with
patients• Clarify strengths and aspirations, evoke
their own motivations for change, and promote autonomy of decision making.
Care planning
Resources
Shared decision making, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/
Tools for shared decision making, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/tools-sdm/
Care Planning, Royal College of General Practitioners http://www.rcgp.org.uk/clinical-and-research/clinical-resources/care-planning.aspx
Embedding SDM in NHS care: Resources developed by Capita, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/resources/capita/
Back to care planning
Health & care professionals committed to partnership
working
Motivational Support
Resources
Motivational Interviewing in Primary Care, Tim Anstisshttp://www.networks.nhs.uk/discussion/soapbox/130950854/232769575/motivational-interviewing-in-primary-care-pdf
Motivational interviewing 1: background, principles and application in healthcare, The Nursing Timeshttp://www.nursingtimes.net/motivational-interviewing-1-background-principles-and-application-in-healthcare/5018759.article
Health Coaching, NHS Direct http://www.nhsdirect.nhs.uk/Commissioners2/HealthCoaching
Co-creating Health, Health Foundation http://www.health.org.uk/areas-of-work/programmes/co-creating-health/
Back to care planning
Health & care professionals committed to partnership
working
Care Planning
The organisation of health and social care services practices should be structured to support thecare planning process. The process involves professionals working in partnership with people livingwith long term conditions and their carers, identifying priorities, discussing care and support options,agreeing goals they can achieve themselves, and co-producing a single care plan, that meets theirphysical, social and emotional wellbeing needs regardless of how many long-term conditionsthey have. Back to house
Recording Outputs of Care Planning Consultations
Processes are in place that allow information captured in care planning appointments to be recorded to inform future care planning consultations and future service provision.
Key Components • Information systems to records agreed goals• Access to menus of available services to
support individuals to achieve their goals • Information systems to record gaps between
individual preferences and services provided to inform commissioning
Care Planning Structure
Services should to be configured to support the ongoing collaborative care planning process.
Key Components• Allowing time for multiple long term conditions to be
considered where required • Allowing information on clinical test results to be
provided to the patient and the professional prior to the care planning discussion
• Considering the frequency of appointments and reviews to provide an opportunities to review short and longer term goals and have mechanisms in place for patient recall
Organisational and Clinical Processes
Care Planning Structure
Resources
Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care, NHS Diabetes https://www.diabetes.org.uk/Documents/nhs-diabetes/care-planning/partners-in-care-implementing-care-planning-approach.pdf
Care Planning Improving the Lives of People with Long Term Conditions, Royal College of General Practitionershttp://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/Cancer/Improving%20the%20Lives%20of%20people%20with%20LTC%20-%202012%2005%2009.ashx
Back to care planning
Organisational and Clinical Processes
Recording Outputs of Care Planning Consultations
Resources
Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care, NHS Diabetes https://www.diabetes.org.uk/Documents/nhs-diabetes/care-planning/partners-in-care-implementing-care-planning-approach.pdf
Back to care planning
Organisational and Clinical Processes
Safety and Experience
Back to house
ExperienceEnsuring processes are in place so that the
experience of the service users can be recorded and reviewed so that services delivered reflect the needs and preferences of people living with long
term conditions and their carers.
Key components• Mechanisms are in place to capture the
experiences of people living with long term conditions and their families and carers
• These experiences inform future planning and delivery of services
Safety Promoting an active safety management approach to identify potential risk while helping to improve monitoring and measuring of safety indicators.
Key Components• Evidence based procedures in place promoting safety• Potential safety concerns identified and addressed • Processes for identifying adverse incidents and near
misses• Safety concerns are freely raised and openly
discussed • Safe processes to optimise the use of medicines
Organisational and Clinical Processes
People with long term conditions should receive high quality care that is safe and reliable and that also delivers excellent patient experience. Processes should be in place to ensure patient experience is captured and to allow safety concerns to be identified and risks for future incidents to be reduced.
Safety
ResourcesPatient Safety, NHS England http://www.england.nhs.uk/ourwork/patientsafety/
European Union Network for Patient Safety and Quality of Carehttp://www.pasq.eu/
Patient Safety Resource Centre, The Health Foundation http://patientsafety.health.org.uk/?gclid=COHtiuyQ07wCFSgKwwodbj0Axg
Patient Safety, Practical information, tools and support to improve patient safety in the NHShttp://www.nrls.npsa.nhs.uk/
Medicines Optimisation: Helping patients to make the most of medicinesGood practice guidance for healthcare professionals in England, Royal Pharmaceutical Society. http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf
Good practice in prescribing and managing medicines and devices, General Medical Councilhttp://www.gmc-uk.org/Prescribing_Guidance__2013__50955425.pdf
Back to safety and experience
Organisational and Clinical Processes
http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf
Experience
Resources
Improving Patient Experience, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/
6 C’s Compassion in Practice, NHS England http://www.england.nhs.uk/nursingvision/
Transforming Patient Experience, NHS Institute http://www.institute.nhs.uk/patient_experience/guide/the_patient_experience_research.html Patient Experience, Kings Fund http://www.kingsfund.org.uk/topics/patient-experience
Organisational and Clinical Processes
Back to safety and experience
Information and Technology
Information and technology is a key factor underpinning successful organisational and clinical processes to support people living with long term conditions and their carers. Two Important elements of this are how information and technology can be used to identify which Individuals in a population will most benefit from care and to share information about these individuals both within and between organisations.
Back to house
Information systems
Professionals are required to have timely and relevant access to information in order to effectively manage people living with long term conditions.
Key Components • Information sharing and access of records
across organisational boundaries • Integrated information systems is key to
ensuring the care is delivered around the needs of the individual as a whole.
Risk Stratification
Using relationships in historic population data to estimate the future use of health care services for each member of a population.
Key Components • Use of information from primary and secondary care
services in addition to social care data • Useful both for population planning purposes and
for identifying which patients should be offered targeted, preventive support.
Organisational and Clinical Processes
Risk Stratification
ResourcesRisk Stratification, NHS Englandhttp://www.england.nhs.uk/ourwork/tsd/ig/risk-stratification/
Predicting and reducing re-admission to hospital, The Kings Fundhttp://www.kingsfund.org.uk/projects/predicting-and-reducing-re-admission-hospital
RISKPROFILING AND CARE MANAGEMENT SCHEME, NHS Englandhttp://www.england.nhs.uk/wp-content/uploads/2013/03/ess-risk-profiling.pdf
Risk Prediction Network, NHS networks http://www.networks.nhs.uk/nhs-networks/risk-prediction-network/?searchterm=risk%20stratificationInformation Governance and Risk Stratification: Advice and Options for CCGs and GPs
http://www.england.nhs.uk/wp-content/uploads/2013/06/ig-risk-ccg-gp.pdf
Advice on Risk Prediction and Stratification, London: National Information Governance Board for Health and Social Care, July 2012 http://www.nigb.nhs.uk/pubs/guidance/riskpred.pdf
Back to information and technology
Organisational and Clinical Processes
Resources
Better information means better care, NHS Englandhttp://www.england.nhs.uk/ourwork/tsd/care-data/
Keeping your online health and social care records safe and secure, NHS Englandhttp://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Documents/PatientGuidanceBooklet.pdf
New technology can improve the health services delivered to millions of people, NHS Englandhttp://www.england.nhs.uk/2013/11/15/new-tech-imprv-hlt-serv/
Back to information and technology
Organisational and Clinical Processes
Information Systems
Guidelines, Evidence and National Audits
Ensuring the services delivered to provide person centred care for people living with long term conditions follow the appropriate guidelines and based on robust evidence where this is available.
Back to house
Organisational and Clinical Processes
National Audits
Audits allow health organisations to compare their performance against specific
standards and national trends, enabling them to deliver better
care for their patients.
Key Components• Usually conducted in disease
specific areas such as COPD, Kidney Disease or Stroke.
Guidelines
To help professionals deliver the best possible care offering the
best value for money. Key Components
• Independent, authoritative and evidence-based information
• Effective ways to prevent, diagnose and treat disease and ill health, reducing inequalities and variation.
• Specific diseases as well as generic principles for care.
Evidence Based Practice
The use of robust evidence to inform the commissioning and delivery of services in practice.Where evidence is not available
this may involve working with academic institutions to contribute to the body of
evidence available.
Key Components• Routine use of evidence in
service planning and delivery
Guidelines
ResourcesNational Institute of Clinical Excellencehttp://www.nice.org.uk/
Social Care Institute for Excellencehttp://www.scie.org.uk/
Map of Medicine http://www.mapofmedicine.com/
End of Life Care Quality Standard, Public Health Englandhttp://www.endoflifecare-intelligence.org.uk/national_information_standard/
British National Formularyhttp://www.bnf.org/bnf/index.htm
Back to guidelines and national audits
Organisational and Clinical Processes
National Audits
ResourcesClinical audits, Health and Social Care Information Centrehttp://www.hscic.gov.uk/clinicalaudits
Audit and Quality Improvement, British Thoracic Societyhttps://www.brit-thoracic.org.uk/audit-and-quality-improvement/
Audits, University College Londonhttp://www.ucl.ac.uk/nicor/audits
GRASP Audit Tools, PRIMIShttp://www.nottingham.ac.uk/primis/index.aspx
Back to guidelines and national audits
Organisational and Clinical Processes
Evidence Based Practice
Resources
NICE Evidence Search Health and Social Care, NICEhttp://www.evidence.nhs.uk/
The Cochrane Library http://www.thecochranelibrary.com/
Social Care Institute for Excellence http://www.scie.org.uk/
Shared Learning Implementing Evidence Based Practice, NICEhttp://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/shared_learning_implementing_nice_guidance.jsp
Back to guidelines and national audits
Organisational and Clinical Processes
Back to house
Care Delivery
How services and processes are configured to up to promote a person centred approach to care as people with long term conditions move through the health and social care system. This will include how to ensure care is being provided in the most clinically appropriate place whilst paying regard to quality of life and efficiency.
Organisational and Clinical Processes
Workforce
Ensuring workforce processes support professionals to deliver
person centred co-ordinated care for people living with long
term conditions.
Key Components • Training of medical, nursing
allied health professionals and social care workforce
• Consideration of the skill mix of the workforce
Care Closer to Home
Ensuring processes are in place to allow people living with long
term conditions to be cared for in a community setting where this is
clinically appropriate.
Key Components • Access to specialist clinics in
the community • Pathways to prevent
admission and to facilitate earlier discharge from hospital.
Rehabilitation
Following condition exacerbations rehabilitation may be required to promote recovery and prevent
further exacerbations.
Key Components• Generic rehabilitation
programmes such as social care support to return home safely
• Condition specific e.g. stroke or pulmonary rehabilitation.
Workforce
Resources
Long Term Conditions, Skills for Healthhttp://www.skillsforhealth.org.uk/service-area/long-term-conditions/
Improving services for people with long-term conditions through large-scale workforce change, NHS Employers http://www.nhsemployers.org/SiteCollectionDocuments/Improving_services_for_people_with_long-term_conditions_through_large_scale_workforce_change_sc_140906.pdf
Long term conditions e-learning tools for NHS and social care workforce, Department of Healthhttps://www.gov.uk/government/news/long-term-conditions-e-learning-tools-for-nhs-and-social-care-workforce
Back to care delivery
Organisational and Clinical Processes
Care closer to home
Resources
Avoiding hospital admissions Lessons from evidence and experience, The Kings Fundhttp://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/avoiding-hospital-admissions-lessons-from-evidence-experience-ham-imison-jennings-oct10.pdf
Interventions to reduce unplanned hospital admissions: a series of systematic reviews, Purdy S. et al (June 2012) http://www.bristol.ac.uk/primaryhealthcare/docs/projects/unplannedadmissions.pdf
Avoiding hospital admissions What does the research say? The Kings Fund http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010_0.pdf
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Organisational and Clinical Processes
Rehabilitation
Resources
Pulmonary Rehabilitation, National Institute of Clinical Excellencehttp://www.nice.org.uk/guidance/qualitystandards/chronicobstructivepulmonarydisease/pulmonaryrehabilitation.jsp
Stroke Rehabilitation, National Institute of Clinical Excellencehttp://guidance.nice.org.uk/CG162
Improving Patient Outcomes through restructuring Recovery, Rehabilitation and Re-ablement, Department of Healthhttp://www.nhsconfed.org/Training/Documents/RRR%20redesign.pdf
Back to care delivery
Organisational and Clinical Processes
Self management
Empowering people with the confidence and information to look after themselveswhen they can, and visit the GP when they need to, giving people greater control of their own health and encourages healthy behaviours that help prevent ill healthin the long-term.
Personal budgets
Personal health budgets are money in lieu of NHS and social care services. They can be spent on a
range of care and support, including things which are
not traditionally commissioned. They are a
tool for commissioning services at the level of the
individual.Key Components
• Assessment of goals for the personal health budget
• Agreed care plan between the NHS and the individual
Back to house
Lifestyle
Promoting healthy lifestyle choices for people living with long term conditions to ensure they experience a good quality of life and
to reduce their likelihood of developing further
conditions and to reduce their impact on health and
social care service. Key Components
• Every contact counts • Targeted smoking
cessation services • Weight management
services • Exercise programmes
ActivationActivation is a measure of an individual’s knowledge,skill, and confidence for self-management. Higher levels of activation have been associated with reduced healthcare utilisation and positive changes in self management behaviour.
Key Components • Assessment of the
activation levels• Tailoring support levels
of activation• Mechanisms to increase
activation levels
Engaged, informed
individuals and carers
Engaged, informed
individuals and carers
Personal Budgets
Resources
Personal health budgets, NHS England http://www.personalhealthbudgets.england.nhs.uk
Building on a people’s movement for change, People Hubwww.peoplehub.org.uk
Personal Health Budgets Evaluationhttps://www.phbe.org.uk/
Personal Health Budgets Toolkit, NHS Englandhttp://www.personalhealthbudgets.england.nhs.uk/Topics/Toolkit/index.cfm
Direct payments and personal budgets for social care - Commons Library Standard Notehttp://www.parliament.uk/business/publications/research/briefing-papers/SN03735/direct-payments-and-personal-budgets-for-social-care
Back to self management
Engaged, informed
individuals and carers
Lifestyle
Resources
Making Every Contact Count, NHS Yorkshire and Humberhttp://www.makingeverycontactcount.co.uk/
The NHS’ role in the public’s health, NHS Future Forumhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216423/dh_132114.pdf
Enabling People to Live Well, The Health Foundationhttp://www.health.org.uk/publications/enabling-people-to-live-well/
Self Care Forumhttp://www.selfcareforum.org/
Back to self management
Engaged, informed
individuals and carers
Activation
Resources
Changing the culture: resources developed by AQuA, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/resources/aqua/
Summary of the Evidence on Performance of the Patient Activation Measure (PAM), NHS Kidney Carehttp://selfmanagementsupport.health.org.uk/media_manager/public/179/SMS_resource-centre_publications/PatientActivation-1.pdf
Back to self management
Information and Technology Information and technology is a key factor to supporting people living withlong term conditions and their carers to feel engaged with and informed about their care. Professionals should ensure information provided is tailored to meet the needs of the individual. Technology such has telehealth or mobile apps can be used to give individuals independence and allow them to play a greater role in managing their care. Technology can also be used to give people alternative ways of accessing information, education and services.
Digital health
In addition to telehealth and telecare there are
other forms of technology that can support people
living with long term conditions and there
carers.
Key Components• Mobile apps • Video or internet based
consultations • Online forums • Social networking• Email and text contacts• Online education
resources
Back to house
Telehealth and telecare
Telecare and telehealth services use technology to
help people live more independently at home. They include personal
alarms and health-monitoring devicesKey Components
• Assessment of who will benefit most from telehealth/telecare
• Joint assessment and referral process
• Service structures to underpin telehealth and telecare
Engaged, informed
individuals and carers
Information
Personalised packages of information designed to help
people with long-term conditions to feel more
informed and more in control of their health and wellbeing.
Key Components• Information on conditions,
treatments, services and support available.
• Provision of a personalised information resource based on an assessment of the individual’s information needs.
Engaged, informed
individuals and carers
Digital Health
Resources
NHS Choices Health Apps Library, NHS Choices http://apps.nhs.uk/
Long Term Condition Management, Airedale Digital Healthcare Centrehttp://www.airedaledigitalhealthcarecentre.nhs.uk/Long_Term_Condition_Management/
Back to technology
Engaged, informed
individuals and carers
Telehealth and Telecare
Resources
Telecare and telehealth technology, NHS Choiceshttp://www.nhs.uk/Planners/Yourhealth/Pages/Telecare.aspx
Telehealth and telecare, The Kings Fundhttp://www.kingsfund.org.uk/topics/telecare-and-telehealth
3 million liveshttp://3millionlives.innovation.nhs.uk/pg/dashboard
The impact of telehealth and telecare: the Whole System Demonstrator project, Nuffield Trusthttp://www.nuffieldtrust.org.uk/our-work/projects/impact-telehealth-and-telecare-evaluation-whole-system-demonstrator-project
Back to technology
Engaged, informed
individuals and carers
Information
ResourcesInformation Prescription Service, NHS Choiceshttp://www.nhs.uk/ipg/Pages/IPStart.aspx
NHS Choiceshttp://www.nhs.uk/Pages/HomePage.aspx
Information prescriptions - an e learning tool, NHS Employers http://www.nhsemployers.org/PlanningYourWorkforce/educationandtraining/LongTermConditions/InformationPrescriptions/Pages/AboutInformationPrescriptions_Final.aspx
Getting the most out of information prescriptions, Macmillan http://www.macmillan.org.uk/Documents/Newsletter/InfoPrescriptionsBooklet2012.pdf
Social prescribing for mental health – a guide to commissioning and delivery, Care Services Improvement Partnership – North Westhttp://www.centreforwelfarereform.org/uploads/attachment/339/social-prescribing-for-mental-health.pdf
Back to technology
Group and Peer support Patients, carers and volunteer members of the public can offer opportunities to support people living with long term conditions. This support can be offered in the community, through groups set up specifically for this purpose or on an individual level. Peer support is often effective as the people providing the support often have first hand experience of living with a long term condition or caring for someone who does.In addition to the educational impact of courses, many patients value the social support gained from meeting other people who are living with a long-term condition.
Peer support groups
Peer-led support groups are proven to help people
manage long-term conditions by reducing
depression, building self-esteem and improving physical and mental
health.
Key Components • Awareness of peer-
support programmes that are available
• Peer-support groups are considered in the care planning process
Back to house
Lay educator programmes
A Lay Educator is someone who delivers
group education to people with a long term condition alongside a professional. A Lay Educators may have a long term condition, have a family member with a
long term conditionKey Components
• Identification of individuals willing to be lay educators
• Development of programmes that are suitable for delivery by lay educators
Community health champions
People who, with training and support, voluntarily
bring their ability to relate to people and their own life
experience to transform health and well-being in
their communities
Key Components• Champions become
involved in community groups/events and offer informal support people to join in healthy activities
Engaged, informed
individuals and carers
Engaged, informed
individuals and carers
Peer Support Groups
Resources
Developing Peer Support for Long Term Conditions, The Mental Health Foundation http://www.mentalhealth.org.uk/publications/developing-peer-support/
The Power of Peer Support, The Health Foundationhttp://www.health.org.uk/news-and-events/newsletter/the-power-of-peer-support/
Back to peer support
Engaged, informed
individuals and carers
Lay Educator Programmes
Resources
Lay Educator Study, The DESMOND projecthttp://www.desmond-project.org.uk/layeducatorstudy-273.html
Lay educators in asthma self management: Reflections on their training and experiences, Clare Brown a, Jean Hennings b, A.-L. Caress b, M.R. Partridge (2007)http://ipcem.org/RESSOURCES/PDFress/Lay.pdf
Back to peer support
Engaged, informed
individuals and carers
Community Health Champions
Resources
Community Health Champions, Altogether betterhttp://www.altogetherbetter.org.uk/community-health-champions
Community health champions: creating new relationships with patients and communities, NHS Confederationhttp://www.nhsconfed.org/Publications/Factsheets/Pages/community-health-champions.aspx
Changing multiple health behaviours: the contribution of health trainers and community health champions, The Kings Fundhttp://www.kingsfund.org.uk/sites/files/kf/jane-south-community-health-champions-poster-mar13.pdf
Back to peer support
Care Planning People living with long term conditions and their carers working in partnership with professionals, identifying priorities, discussing care and support options, agreeing goals they can achieve themselves. Co-producing a single care plan, that meetstheir physical, social and emotional wellbeing needs regardless of how manylong-term conditions they have.
Consultation preparation
Research by the Health Foundation has identified elements that can make a
consultation between patient and healthcare professional more successful.
Key Components• Receptionist conversations in general
practice • Practice Health Champions• Appointment guides
Back to house
Care planning process
An ongoing process encouraging an interactive partnership between clinician and patient to support self management of patients and their long term condition.
Key Components• Information provided to the patient
prior to the appointment • During the appointment achievable
goals should are set in partnership. • Capturing gaps between preferences
and care received • Feeding back preferences to inform
future planning.
Engaged, informed
individuals and carers
Engaged, informed
individuals and carers
Care Planning Process
Resources
Shared decision making, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/
Tools for shared decision making, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/sdm/tools-sdm/
Care Planning, Royal College of General Practitioners http://www.rcgp.org.uk/clinical-and-research/clinical-resources/care-planning.aspx
Deciding together Care planning in long term conditions, NHS Kidney Care , February 2013http://www.cmkcn.nhs.uk/attachments/article/37/Deciding%20together%20%20Care%20planning%20in%20long%20term%20conditions[1].pdf
Back to care planning
Engaged, informed
individuals and carers
Consultation Preparation
Resources
Right Conversation at the Right Time, The Health Foundation http://www.rightconversation.org/
When doctors and patients talk: making sense of the consultation, The Health Foundation http://www.rightconversation.org/whendoctorsandpatientstalk.pdf
Back to care planning
Carers
There are around 6.5 million people who report that they are carers in the UK (CarersUK, Census Analysis 2012). It is important that the health and wellbeing of carers isconsidered so that they feel supported to continue to care for people living with long term conditions.
Health and wellbeing of carers
Being a carer can have an impact on an individual’s health and wellbeing. The
physical and mental health needs of carers should be considered in addition the wider impact on their quality of life. One key area for consideration is financial pressure for
carers which can come from reduced earnings and increased outgoings related to
the costs of ill health or disability. Key Components
• Identification of the carer population and challenges they might be facing
• Assessment and mechanisms to improve the health and wellbeing status of carers
• Advice and signposting to services that can support with financial and employment pressures
Back to house
Carer support and respite
Access to services which allow carers to continue working, maintain their health and
well-being, keep families together and ensure that carers have a life of their own and are able and willing to continue caring
Key Components• Consultation to understand carer
support needs • Services offering support and respite
depending on the level of need of the individual carer
Engaged, informed
individuals and carers
Engaged, informed
individuals and carers
Health and Wellbeing of Carers
Resources
Carers UKhttp://www.carersuk.org/
Looking After You, Carers UKhttp://www.carersuk.org/help-and-advice/looking-after-you
Carers’ Wellbeing, NHS Choices http://www.nhs.uk/carersdirect/yourself/Pages/Yourownwellbeinghome.aspx
Caring & Family Finances Inquiry , Carers UKhttp://www.carersuk.org/get-involved/caring-family-finances-inquiry
Your Work and Career, Carers UKhttp://www.carersuk.org/help-and-advice/looking-after-you/your-work-and-career
Back to carers
Engaged, informed
individuals and carers
Carer support and respite
Resources
Carers UKhttp://www.carersuk.org/
Practical Help, Carers UKhttp://www.carersuk.org/help-and-advice/practical-help
Evidence-based planning and delivery of local support for carers, Carers UKhttp://www.carersuk.org/professionals/resources/practice-guides/item/3010-evidence-based-planning-and-delivery-of-local-support-for-carers
Carers and the NHS practice briefing , Carers UKhttp://www.carersuk.org/professionals/resources/practice-guides/item/423-carers-and-the-nhs
Back to carers
Commissioning
Metrics and Evaluation
Information to inform commissioning processes and development of metric and outcomes that allow services to be evaluated effectively to ensure meeting the needs of the local population.
Information
Commissioners have a number of key intelligence requirements that need to be addressed to deliver
great commissioning.
Key Components
• Accurate, relevant and timely information that enables commissioners to design and plan cost effective services that will improve the quality of life for people living with long term conditions and their carers.
Back to house
Metric and Outcome DevelopmentMeaningful indicators are set so
performance management metrics reflect the proposed
outcomes of the service whilst being mindful of the practical implications of measurement.
Key Components • Development should consider
nationally set outcomes as well as outcomes set locally.
• Consideration of how metrics can be collected in practice
• SMART (Specific Measurable, Attainable, Realistic, Timely) measures are used
Evaluation
Evaluation should consider the impact the service has on its users in addition to the wider
impact on the health and social care economy as a whole. It
should consider the economic and activity impacts in addition to
service user experience and health and social care outcomes
Key Components • Evaluation criteria set in
service specifications • Consider the if the metrics by
which services are monitored are appropriate
Information
ResourcesLevels of Ambition Atlas, NHS Englandhttp://www.england.nhs.uk/ourwork/sop/plan-sup-tools/a-atlas/
Commissioning for Value – a comprehensive data pack to support CCGs, NHS Englandhttp://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/
Data and knowledge gateway - Public Health Englandhttp://datagateway.phe.org.uk/?lk_sr=govphe
Toolkit published to help improve services and close the financial gap in ‘Any town’ , NHS England http://www.england.nhs.uk/2014/01/24/any-town/
Better data, informed commissioning, driving improved outcomes: clinical data setshttp://www.gowerplacepractice.nhs.uk/files/2013/08/View-a-list-of-codes-that-will-be-used-PDF-205kb.pdf
Statistics, NHS Englandhttp://www.england.nhs.uk/statistics/
Back to metrics and evaly
Commissioning
Resources
CCG outcomes indicator sethttp://www.england.nhs.uk/ccg-ois/
Public Health Outcomes Frameworkhttps://www.gov.uk/government/collections/public-health-outcomes-framework
Measurement Masterclass series for senior clinical leadershttp://www.nhsiq.nhs.uk/capacity-capability/measurement-masterclass.aspx
How to measure for improving outcomes: a guide for commissionershttp://www.kingsfund.org.uk/topics/commissioning/how-measure-improving-outcomes-guide-commissioners
Outcome and metric development
Back to metrics and evaluation
Commissioning
Resources
Evaluating healthcare quality improvement, The Health Foundation. http://www.health.org.uk/publications/evaluating-healthcare-quality-improvement/
Quality and Service Improvement Tools for the NHS, NHS IQhttp://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/quality_and_service_improvement_tools_for_the_nhs.html
Approaches to Economic Evaluation in Social Care, SCIEhttp://www.scie.org.uk/publications/reports/report52.pdf
Social Return on Investment http://www.thesroinetwork.org/what-is-sroi
Back to metrics and evaluation
Commissioning
Evaluation
Commissioning
Needs Assessment and Strategic PlanningAssessment of need for people living with long term conditions and their carers across a whole health economy, considering all health and social care needs to inform future commissioning. Accurate, timely and relevant information for both health and social care is required to ensure to inform thisprocess. The outcomes of the health needs assessment process will inform strategic planning decisions about which services should be commissioned to best meet the needs of the local population. Back to house
Needs AssessmentThe process by which the need for services and other interventions
are fully assessed. It is a vital analysis which underpins any
strategic plan.
Key Components • Epidemiological –information
about the area of interest and potential interventions.
• Comparative –comparing existing services with established standards or with other populations.
• Corporate – capturing the views of stakeholders.
Strategic Planning
Planning across a local health and social care economy,
setting priorities about what should be commissioned to
deliver the best possible outcomes for people living with
long term conditions.
Key Components• Joint priority setting • Determining which services
and pathways will be the most appropriate to meet local need.
Reducing InequalitiesThe numbers of people living with
long term conditions and the corresponding impact they have on
health and social care is not distributed evenly across a population. Tackling health
inequalities is a key consideration for commissioning services for
people living with long term conditions
Key Components • Identifying those at greater risk of
developing long term conditions • Identifying those who may needs
extra support to manage their condition(s).
Strategic Planning
ResourcesStrategic and Operational Planning 2014 to 2019, NHS Englandhttp://www.england.nhs.uk/ourwork/sop/
Wellbeing and health policyhttps://www.gov.uk/government/publications/wellbeing-and-health-policy
Improving the public's health - A resource for local authorities (Dec 2013), The Kings Fundhttp://www.kingsfund.org.uk/publications/improving-publics-health
Delivering better services for people with long-term conditions -Building the house of care, The Kings Fundhttp://www.kingsfund.org.uk/publications/delivering-better-services-people-long-term-conditions
Commissioning High Quality Care for People with Long Term Conditions, The Nuffield Trusthttp://www.nuffieldtrust.org.uk/publications/commissioning-high-quality-care-people-long-term-conditions?gclid=COTpweS3xrwCFSvHtAodG1oAVg
Back to Needs Assessment and Planning
Commissioning
Needs Assessment
Resources
Modelling toolhttp://www.local.gov.uk/web/guest/health/-/journal_content/56/10180/4060433/ARTICLE Clustering of unhealthy behaviours over time Implications for policy and practicehttp://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-time
Joint Strategic Needs Assessment, NHS Confederation http://www.nhsconfed.org/Publications/briefings/Pages/joint-strategic-needs-assessment.aspx
Joint Strategic Needs Assessment, Health and Social Care Information Centrehttp://www.hscic.gov.uk/jsna
Back to Needs Assessment and Planning
Effective Commissioning
Reducing Inequalities
Resources
Health Inequalities Gap Measurement Tool, Public Health Englandhttp://www.sepho.org.uk/gap_intro.aspx
Health Inequalities Intervention Toolkit, Department of Healthhttp://www.lho.org.uk/LHO_Topics/Analytic_Tools/HealthInequalitiesInterventionToolkit.aspx
Health inequalities: concepts, frameworks and policy, NICEhttp://www.nice.org.uk/niceMedia/documents/health_inequalities_concepts.pdf
Back to Needs Assessment and Planning
Commissioning
Back to house
Joint Commissioning of Services
Health and social care commissioners working together to decide what kinds of services should be provided to local populations, who should provide them and how they should be paid for to promote integration across health and social care. Considering long term conditions commissioning across thewhole pathway of care ensuring services are commissioned and provided according to the needs of the individual reducing barriers imposed by organisational boundaries.
Shared FundingShared funding can facilitate joint commissioning supporting health and social care commissioners to work closely together to decide
together how to allocate resources to deliver the best
outcomes across the health and social care economy.
Key Components• Mechanisms for sharing or
pooling resources• Mechanisms for deciding how
joint resources will be allocated
Back to house
Commissioning Responsibilities
Knowledge of the statutory obligations of the different organisations involved in commissioning services.
Organisations working together to ensure joint accountability of
outcomes across the whole system Key Components
• Understanding “who is responsible for what” to allow integrated pathways to be created and commissioned effectively.
Integrated pathway and service development
Colleagues across health and social care working in
partnership to commission integrated pathways of care
meet the needs of the individual Key Components
• Commissioning pathways that allow how health and social care professionals to work closely together to offer seamless pathways of care
• Commissioning of services that patients and carers feel are well coordinated.
Commissioning
Resources
Integrated Care – Better Care Fund – Local Government Associationhttp://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE
Better Care Fund Planning – NHS England http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/
Making best use of the Better Care Fund Spending to save? (Jan 2014)http://www.kingsfund.org.uk/publications/making-best-use-better-care-fund
Year of Care, NHS Improving Quality http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/year-of-care.aspx
Shared Funding
Back to joint commissioning of services
Commissioning
ResourcesA framework for collaborative commissioning between clinical commissioning groupshttp://www.england.nhs.uk/wp-content/uploads/2012/03/collab-commiss-frame.pdf
Commissioning fact sheet for clinical commissioning groupshttp://www.england.nhs.uk/wp-content/uploads/2012/09/fs-ccg-respon.pdf
Public health commissioning in the NHS 2014 to 2015https://www.gov.uk/government/publications/public-health-commissioning-in-the-nhs-2014-to-2015
Working together to deliver the Mandate Strengthening partnerships between the NHS and the voluntary sectorhttp://www.kingsfund.org.uk/publications/working-together-deliver-mandate
Who Pays? Determining responsibility for payments to providers, August 2013, NHS England http://www.england.nhs.uk/wp-content/uploads/2013/08/who-pays-aug13.pdf
Commissioning Responsibilities
Back to joint commissioning of services
Commissioning
Resources
Winterbourne View Joint Improvement Programme, Local Government Association http://www.local.gov.uk/web/guest/adult-social-care/-/journal_content/56/10180/3912043/ARTICLE
Integrated care for patients and populations: Improving outcomes by working together - A report to the Department of Health and the NHS Future Forum, Kings Fundhttp://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together
Integrated Care – Better Care Fund, Local Government Associationhttp://www.local.gov.uk/web/guest/health-wellbeing-and-adult-social-care/-/journal_content/56/10180/4096799/ARTICLE
Integrated working for better outcomes, Social Care Institute for Excellence http://www.scie.org.uk/publications/integratedworking/
Integrated Pathway and Service Development
Back to joint commissioning of services
Commissioning
Service User and Public Involvement
Ensuring that the people likely to receive services and their carers are involved in the planning and commissioning of services. This might be through patient and public Involvement at a population level or with service users and carers at an individual level.
Back to house
Involvement in planning
Service user involvement is one of the most important measures and determinants of quality in health and social care planning and delivery
By involving services users and members of the public commissioning should result in high-
quality services that more adequately reflect user need.
Key Components• Routine involvement of service users and
carers in service planning
Service User Experience
Ensuring that their views of service users and carers are captured so that services commissioned reflect the needs and preferences of people living
with long term conditions and their carers.
Key components• Mechanisms are in place to capture the
experiences of people living with long term conditions and their families and carers
• These experiences inform future commissioning of services
Commissioning
ResourcesTransforming Participation in Health and Care, Guidance for Commissioners, NHS Englandhttp://www.england.nhs.uk/2013/09/25/trans-part/
Invest In Engagement, Picker Institute Europe http://www.investinengagement.info/
Community commissioning case studieshttps://www.gov.uk/government/publications/community-commissioning-case-studies
Patient involvement , National Voiceshttp://www.nationalvoices.org.uk/patient-involvement
People Powered Health, Nesta http://www.nesta.org.uk/project/people-powered-health
Involving and consulting carers - a good practice guide, Carers UKhttp://www.carersuk.org/professionals/resources/practice-guides/item/428-involving-and-consulting-carers-a-good-practice-guide
Involvement in planning
Back to Service and Public User Involvement
Commissioning
ResourcesPatient involvement , National Voiceshttp://www.nationalvoices.org.uk/patient-involvement
Experience Based Design, NHS IQhttp://www.institute.nhs.uk/quality_and_value/experienced_based_design/the_ebd_approach_(experience_based_design).html
Involving and consulting carers - a good practice guide, Carers UKhttp://www.carersuk.org/professionals/resources/practice-guides/item/428-involving-and-consulting-carers-a-good-practice-guide
Improving Patient Experience, NHS Englandhttp://www.england.nhs.uk/ourwork/pe/
Transforming Patient Experience, NHS Institute http://www.institute.nhs.uk/patient_experience/guide/the_patient_experience_research.html
Patient Experience, Kings Fund http://www.kingsfund.org.uk/topics/patient-experience
Service User Experience
Back to Service and Public User Involvement
Commissioning
Contracting and Procurement
Developing the levers and incentives to enable professionals to deliver person centred coordinated care for people living with long term conditions. Managing the process of tendering for thesupply of goods and services and awarding contracts. Agree process by which new service/pathway will be contracted for Back to house
Reorientation Ongoing evaluation process of
commissioned services ensuring the services provided continue to
meet the needs of changing populations. Where services are no longer evaluated as effective
this may involve decommissioning services and commissioning new
services that better meet the needs of the population.
Key Components • Regular evaluation of existing
services • Processes for decommissioning
services that maintain continuity and minimise disruption
Service SpecificationsDocumentation which sets out
the necessary requirements of a commissioned service. These
documents are key to the contracting process as they not
only describe what form the service should take but also how
success will be measured and how performance management
will take place.Key Components
• Service specifications• The use of service
specifications to develop meaningful performance and quality indicators
Commissioning
Contracting Models
To ensure contracting models are the most appropriate for the
service commissioned. To consider models that can be commissioned jointly across
health and social care.
Key Components • Statutory procurement
processes • Standard contract models• Joint contracting models
Resources
2014/15 Standard Contract, NHS England http://www.england.nhs.uk/nhs-standard-contract/
The NHS Standard Contract: a guide for clinical commissioners, NHS Englandhttp://www.england.nhs.uk/wp-content/uploads/2013/02/contract-guide-clinical.pdf
Making savings from contract management, Local Government Association http://www.local.gov.uk/documents/10180/11417/Making_savings_through_contract_management.pdf/e56aeb46-7d56-4327-b8ff-8824d136aff7
Contracting Models
Back to contracting and procurement
Commissioning
Resources
Guidance for commissioners on ensuring the continuity of health care services, Monitorhttp://www.monitor.gov.uk/node/2462
P3M Resource Centre, Delivering the benefits of change, NHS Connecting for Health http://www.connectingforhealth.nhs.uk/systemsandservices/icd/informspec/p3m/resource
Reorientation
Back to contracting and procurement
Commissioning
Resources
Commissioning toolkit for respiratory services, Department of Healthhttps://www.gov.uk/government/publications/commissioning-toolkit-for-respiratory-services
Support for Commissioning Dementia Care, NICEhttp://publications.nice.org.uk/support-for-commissioning-dementia-care-cmg48
Service Specifications
Back to contracting and procurement
Commissioning
Care Planning
Back to house
Commissioning to support care planning
Commissioners for long term conditions services need to
consider how services can be configured to best support the
collaborative care planning process.
Key Components • Commissioning supporting
care planning appointment structures in primary care
• Directory of Services • Commissioning to support
the information needs of the care planning process
Care planning to support commissioning
Ensuring that outputs from the care planning process are fed
into the commissioning process.
Key Components• Recording gaps between
individual requirements and services commissioned
• Commissioning mechanisms to capture and transfer care planning information
• Directory of services • Using care planning
information to routinely inform the commissioning process.
Commissioning
Care planning aims to make best use of health care and local authority services through capturing the needs and preferences of people living with long term conditions and their carers and ensuring this information is fed into commissioning processes. In order for this to happen commissioners for long term conditions services need to consider how services can be configured to best support the collaborative care planning process.
Personal Budgets
Personal budgets are essentially a tool for
commissioning services at the level of the individual. Personal
health budgets are money in lieu of NHS or social care
funded services which is spent as detailed in an agreed care
plan.
Key Components • Providing people living with
long term conditions with the option of a personal health or
social care budget • Directory of Services
Resources
How information supports personalised care planning and self care, Department of Healthhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215952/dh_124054.pdf
At a glance 45: Social care and clinical commissioning for people with long-term conditions, SCIEhttp://www.scie.org.uk/publications/ataglance/ataglance45.asp
Delivering better services for people with long-term conditions, Building the house of care . Kings Fundhttp://www.kingsfund.org.uk/publications/delivering-better-services-people-long-term-conditions
What is a directory of services? Connecting for Healthhttp://www.connectingforhealth.nhs.uk/systemsandservices/pathways/about/dos
Commissioning to Support Care Planning
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Commissioning
Resources
Long Term Conditions (LTC) Electronic Templates Supporting Personalised Care Planning, NHS Networks http://www.networks.nhs.uk/nhs-networks/long-term-conditions-ltc-electronic-templates/show_all_similar_networks
Care Planning, Diabetes UKhttp://www.diabetes.org.uk/Documents/nhs-diabetes/care-planning/knowledge-information-repository-care-planning-diabetes-executive-summary.pdf What is a directory of services? Connecting for Healthhttp://www.connectingforhealth.nhs.uk/systemsandservices/pathways/about/dos
Care Planning to Support Commissioning
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Commissioning
Resources
Personal health budgets, NHS England http://www.personalhealthbudgets.england.nhs.uk
Building on a people’s movement for change, People Hubwww.peoplehub.org.uk
Personal Health Budgets Evaluationhttps://phbe.org.uk/
Personal Budgets
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Commissioning
Tools and Levers
The use of tools and levers to allow for effective commissioning processes to achieve the best outcomesfor the health and social care economy. This can include the use of different tariff models to fund health and social care support to those with complex needs and commissioning of direct and local enhanced services.
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Enhanced Services
Enhanced services are those which are commissioned outside of the core primary care contract. They are commissioned where additional need is identified. Enhanced services can be developed locally and nationally to support people living wit h long term
conditions.
Key Components• Evaluation current services and identifying gaps in
need that could be met through the commissioning of an enhanced service
• Direct enhanced services (national level)• Local enhanced services (local level)
Commissioning
Tariff and Funding Models
Whole population tariff models are not always the most effective methods for funding care for people
living with complex long term conditions. Alternative tariff or funding models can be considered based on the health and social care needs of and individual
rather than based on disease. These models consider an annual risk adjusted capitation budget
which is based on these levels of need.
Key Components• Local changes to tariff to support people with
complex needs• Risk stratification and identification of those with
complex care needs • Year of Care Funding Model
Resources
Enhanced Services Commissioning Factsheet, NHS England http://www.england.nhs.uk/wp-content/uploads/2012/03/fact-enhanced-serv.pdf
Enhanced Services, NHS Employers http://www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/DirectedEnhancedServices/Pages/EnhancedServices.aspx
Enhanced Services
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Commissioning
Resources
Year of Care, NHS Improving Quality http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/year-of-care.aspx
Confirmation of the 2014/15 National Tariff, NHS England http://www.england.nhs.uk/resources/pay-syst/national-tariff/
Tariff and Funding Models
Commissioning
Back to tools and levers
The House of Care – Build your own houseWhat elements need to be in place for YOUR local population?
Commissioning
Organisational and clinical processes
Engaged, informed individuals & carers
Health & care professionals committed to partnership working
Back to house
