Organisational Journey Supporting self-management for people living with long-term conditions...
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Transcript of Organisational Journey Supporting self-management for people living with long-term conditions...
Organisational Journey
Supporting self-managementfor people living with long-term
conditionsconditions
Organisational Journey
http://personcentredcare.health.org.uk
Our Journeys
2005 -2007
Pre-CCHSelf Mgt
Work- streams/ strategy
EPP
Health Trainers
2007-2010- Co-Creating Health 1Developing p’ships
Year of Care
Implementing SMPs & ADP
2010-2012
Co-Creating Health 2Sustainability & Spread
Commissioning/ 3rd Sector : NESTA
2013-2015
Continuing SMSSynergies with local strategic drivers
Embedding
Good practice
Self Mgt Support Networks
More Development of P-ship Models
2015-
Next StepsDevelopment of
Clinical Strategies
Development of Strategies to work with Education Providers (more widely)
Building Capacity
Continuing with culture change
Commissioning
http://personcentredcare.health.org.uk
Backdrop to our journeys• Change in NHS – Organisational and
Commissioning• Policy Change – Recognition of the
importance of developing services to better meet needs of people living with long-term conditions
• Integrated Care Models• Better Care Fund 2013• Care Act 2014
http://personcentredcare.health.org.uk
Backdrop to our journeysHouse of Care Model
“More than medicine”Informal and formal sources of support and care sustained by the
responsive allocation of resources
Progress
Transformative – patient and clinician relationship Self-Management Programmes for people living with a
variety of long-term health conditions Self-management support built into delivery models for
patient services Peer Support Groups open to patients following self-
management programmes which meet regularly Collaborative delivery with health-care professional and
lay-facilitators
http://personcentredcare.health.org.uk
Progress
Award winning programmes Inter-professional training offered for all staff and to
support whole staff teams Training delivered to Medical Students and Specialist
Registrars Diversification of training to reach different front line
staff audiences. Eg: GP Receptionists; Pharmacists.
http://personcentredcare.health.org.uk
Progress
Self-Management Support NetworkContribution to national learning through
Co-Creating Health and beyondRecognised as National leaders in the field
http://personcentredcare.health.org.uk
Progress
Enabler of Strategic priorities & development of other services
Ongoing interest from national and local policy makers and commissioners
http://personcentredcare.health.org.uk
Enabler of integrated care
“Self Management Network and self management support work have linked different parts of the organisation that previously have had no obvious connections, and have connected to local authority and voluntary services too!”
“Self management support is increasingly finding its way into peoples’ vocabulary, strategic plans and service objectives”
“This is the first time I have felt like part of an Integrated Care Organisation”
ChallengesLeadership & Supportive infrastructure• Building /resourcing whole-systems approach across
the patch• Developing a common language across the WHOLE
local economy• Outreach to whole workforce at the same time• Clear and consistent approach to supporting self-
management – keeping consistent standards • Cultural shift – time and focus needed – huge
numbers • Whilst all sites have some good strategic leaders and
clinical / managerial leadership – it is not consistent across all parts of the system
Challenges
Engaging Service Users• Patient Power remains under-utilised
Skills /development• Maintaining capacity to deliver programmes• When Teams are to be supported, significant effort and
investment can be required, for example, staff can lack confidence at the beginning of their journey; service specifications may need to change to support self-management; skills need to be practiced
Commissioning• Commissioning and securing future commitment to SMS
Engaged, inform
ed patient
HCP com
mitt
ed to partnership w
orking
Organisational processes
Commissioning – The foundation
Building the house with
ALL providers
Scaling up; building capacity
Must review what is already
being done
Move from disease specific
silos
Didn’t develop outcome
measures at the start
Infrastructures/ IT systems do not support shared care
and support planNHSE care planning template
Fragmented commissioning system/tariffs
Pressure of TIME for good conversations
Annual funding cycle
challenging to providers
Competency framework
patient safety connection
Reinforcing new ways
My job?
Capacity -TIME
Capacity -100’s of clinicians to reach
“I’m already doing this” – “unknown unknown”
Deprivation and low levels of
activation
Peer support and “more than
medicine”
Reaching people
1000’s of people to reach
Key learning themes
• Align and integrate • Engage• Good leadership• Passion, belief and resilience• Work collaboratively• Understand what drives behaviour change
and link to SMS • Resources in the current climate• Networking
http://personcentredcare.health.org.uk
Committed and respectedleadership engaging the staff
A culture hospitable and supportive of change
Data and analytics that measure and communicate impact
Management practices that ensure execution and implementation
An enabling environment which
supports and drives change
Resources and support to do the
work of change
Capabilities and skills to identify
and solve problems
Image from: Constructive comfort: accelerating change in the NHS, The Health Foundation, February 2015http://www.health.org.uk/publications/constructive-comfort-accelerating-change-in-the-nhs/
Practical tools & resources to help clinicians understand and implement Person-centred care
http://personcentredcare.health.org.uk