Triangulation: When is a light an axis?

 

...when there are two lights ...

32c St. Joseph single
https://postalmuseum.si.edu/object/npm_1996.2066.165

See also:

https://en.wikipedia.org/wiki/St._Joseph_North_Pier_Inner_and_Outer_Lights

 

CLEAR as a Mental Health Million...?

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

ASK  about underlying social problems	TREAT  the immediate health problem ...
REFER to local social support resources	ADVOCATE for

Constantly rationalising; it's still the Northern summer holidays, people are away, not everyone's on twitter, the tweet's still warm, blimey - get a life ...!

I wonder how no one else can consider the very obvious 'fit' between key elements of the CLEAR initiative and Hodges' model, sufficient to consider the tweet of that post worthy of a like at least? Not a one. (There's another post perhaps..?)

Oh well... Plough on ...

The other week Mental Health Million on twitter featured a gif that caught my eye again today. This graphic provides a lesson that also incorporates CLEAR.

If we consider the ASK advice, then this supposes of course that the person, patient, client is engaged with the health professional. Engaged, to such an extent that in competency terms the professional's interpersonal skills come to the fore. It really is how we ask, and at that first encounter that is crucial.

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

ASK  about underlying social problems	TREAT  the immediate health problem ...
REFER to local social support resources	ADVOCATE for

Although I may write about the importance of parity of esteem in mental and physical health this is often thought of in funding, research terms and the physical health of people with more chronic forms of mental illnesses who are prescribed and take long term psychotropic medication. It is not easy to envisage the extent of the challenges for patients, their families and the health and social care team. The CLEAR website notes the use of the initiative across many health contexts and hence conditions, including dementia.

The animation tweeted by Mental Health Million and their reference to the 'One in Four' statistic, highlights the complex nature of 'care pathways'.

Yes, the solutions are "out there" but the key is making them available.

No pun intended, but pathways are often taken for granted in the sense that they are CLEARed and straightforward to follow. CLEAR checks this assumption and takes a global approach. CLEAR and Hodges' model draw attention to the humanistic, the social side of medicine, health care. These are often not factored in from the outset, as a vital part of the outcome process (policy, purposes and practices).

As mental health care professionals realise that ability to 'ask' can be hard-won in terms of the patience that needs to be exercised.
The counterpoint to that is a twitter thread last week. A person with mental illness and in difficulty at that time, was suggesting that the professionals "Go Away" (not exactly the words used).

As this animation suggests, getting referred is one thing, being heard and seen is another. Getting to the point were dialogue is possible is a delicate negotiation. Mutual respect, being able to agree to disagree. Do we agree as to the type of the fruit on the tree; never mind what might be 'low-hanging'?  Whatever the perceived and actual differences we must try to reduce that distance, listen, share and make progress.

No one should have to sit, walk, Be alone if they do not want to. ...

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

When you report an eating disorder to the medical profession, but your BMI is within *normal* range. pic.twitter.com/BCFJnnJ6yo — MentalHealthMillion (@MentalHealthMil) September 3, 2019	TREAT the immediate health problem
REFER to local social support resources	ADVOCATE for

Evidence for simplicity, genericity, openness and holistic competence

N-th mover to Integrated, Person-Centered and Holistic Care

walk the talk, sour grapes, or holistic humbug?

Although, sadly (and all down to me) I stepped off the PhD programme with an MRes, the intention was not to bring my journey with Hodges' model to a close. The joke of course with this model is that you are always presented with a crossroads. As I've written previously (even in draft!) this model is a baton to pass on to others. If the workforce of the 1970s to date evaluates its contribution to health care change and progress, then while the achievements speak for themselves, the challenges^* that remain still shout out:

1. parity of esteem 
2. integrated - co-ordinated and collaborative care

This week I received an email, purely as a list member I must add:

NHS Innovation Accelerator 

Applications for the 2017 NHS Innovation Accelerator (NIA) are now open. For 2017, the NIA is seeking local, national and international innovations that address the following NHS priorities:

·         Mental Health
·         Urgent and Emergency Care
·         Primary Care

The above is now closed but I immediately thought about Hodges' model, given that from the information provided mental health is a priority and a top priority for citizens. Plus, the things that can make a difference to problems:

• Suicide and relapse prevention
• Access and availability with a focus on perinatal, children and young people, dementia and psychological therapies
• Early identification and intervention to minimise the impact on a person’s life, the likelihood of escalation and, in some cases, the chances of survival
• Care closer to home including self-care and access to services at home, in a primary or community setting
• Holistic care of both mental and physical health needs including prevention, screening and treatment for those at greatest risk of poor physical health   

"There are many innovations available to improve mental health services, however they are not always used..."

There are however a series of requirements, which present a stumbling block as high impact evidence is lacking.

The purpose of NHS Innovation Accelerator lies in the name. The target is established initiatives and projects that would benefit the NHS and others from a boost of further momentum and leadership support including funding and mentoring. Hodges' model is far from this, but the call is interesting nonetheless.

Reading the details I can argue, for example, that Hodges' model is immediately applicable across the life-span. The model is already designed, but in use the model could be said to meet the requirement of being co-designed with people (including carers, where appropriate). I have used the model with patients and carers (young and adult) who have lived experience of mental illness. With some consideration of the patient, carer, as I have stressed here before on W2tQ the model is accessible to a diverse population. Critically, the delivery of the most significant benefit in terms of outcomes and cost savings needs proof.

It seems that many of the world's problems could be ameliorated through education. This has been evidenced for decades and yet globally there are those who politicise their respective educational system, or even worse deny sections of a society access to education.

In healthcare how can we demonstrate the effectiveness of what is basically a back-of-an-envelope tool? While not a solution Hodges' model helps us to resolve the constituents of healthcare demand and supply, to critically analyse and synthesize - what is going on? I'm sure Hodges' model is just one of many local 'innovations' (in this case created in NW England) that are not evidenced and are therefore missed. Why is this? It may be that the model needs to be re-discovered since being invented somewhere else, by somebody else makes it a non-starter. Similarly, reading the information 'model of care' always grabs my attention:

Your innovation can be a device, digital app or platform, 

a service, process, pathway or model of care. 

But as is often the case, this is framed in service commissioning, funding, delivery and yes patient outcomes terms. Devices, apps, platforms and services can be specified to a high degree. This is essential to success in research (as is dissemination). Aims and objectives can then be clearly defined, outcomes can be recognised and measured. Processes and pathways are perhaps more fuzzy? These are all important tools, aspects and contexts in health care.

My frustration is that this and similar research formulations seem to exclude tools and resources that are by their nature intentionally simple, holistic, generic and cognitive-reflective. The "model of care" is broken. A whole systems approach^# is needed that incorporates education and with it prevention and staying well; plus caring for those affected by illness and disease. We have to honour the legacy problems that the political, education and health systems have 'delivered'. Even if not broken the model of care is missing its twin, the model of life-style choices'.

I still believe there is a model - a conceptual framework - that must precede the (politicised?) model of care, if health and social care are to be truly transformed. Without this, well yes the NHS can accelerate, staff have demonstrated this repeatedly while negotiating all sorts of obstacles. The line of travel will however be circular; circular, but without the discoveries and change gifted to the particle physicists.

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

education mental health cognitive access benefits - outcomes subjective	Evidence process primary care, accident and emergency physical access objective
qualitative home social care co-design public engagement	quantitative strategy 'model of care' education system citizens cost savings

My source: 
Irina Johnston
CHAIN Administrative Assistant

If you wish to publicise information on the CHAIN Network please email your request to: enquiries AT chain-network.org.uk

CHAIN - Contact, Help, Advice and Information Network – is an online international network for people working in health and social care. For more information on CHAIN and joining the network please visit website: www.chain-network.org.uk

^*

1. parity of esteem (a very broad interpretation - the comparison and contrasts between mental health and physical care on several levels - demand, supply, funding, research, integration, staffing, policy, outcomes, evidence-base, social determinants...)
2. integrated - co-ordinated and collaborative care (this is not one thing, but several. These terms are sometimes used interchangeably. Care that is truly integrated will also be co-ordinated and collaborative.

^# This is not recourse to jargon, Hodges' model implies several systems from the outset.

"Model hospital": Where to find 5mins per shift? (footprints - transformation?)

individual

|

INTERPERSONAL : SCIENCES

humanistic ---------------------------------------  mechanistic

SOCIOLOGY : POLITICAL

|

group

Mental health	8,500 beds blocked costing NHS providers around £900m per year 5 mins
Social care	Operational productivity and performance in English NHS acute hospitals: Unwarranted variations £280m delayed transfers of care independent sector expenditure costs £482m lack of data (still!) Stepdown facilities

"On staff rosters, Lord Carter said he found cases in which trusts were squeezing nurses on to weekday shifts in order to make up their weekly hours, and said 

 improving productivity by five minutes per shift could save as much as £280m." (p.11)

<>

Model - hospital : Model - community care : Model - self-care?

Scope of disciplines

Scope of nursing... (draft paper)

Scope of footprints

Scope of transformation?

Additional link:
NHS England (March 2016) Sustainability and Transformation Plan footprints, Ref: 04902.

My source: 

Dunhill, L. (2016) Carter: be masters of your fate, Health Service Journal, 10 February, 126: 6475, 10-11.

Care pathways: 15 minutes on Monday - how far is that?

On Monday I have a quick visit for 15 minute slot on care pathways at an interprofessional study day for 2nd and 3rd year students.

After the short presentation I'll ask the question of what difference the students can make to the patient's care pathway. There may be value in continuing the 'journey' metaphor?

They can ensure the care pathway is well-documented (otherwise it doesn't exist, and travel on it never happened) they can check it is accessible (an achievable goal) and that it does not trip anyone up (we don't do - iatrogenic).

There are further tests: is it navigable, tried and tested, a safe (evidenced-based) route? As the student's contemplate a major step in their health career, we really need them to focus on the health career of the persons in their care.

[ There won't be time for this: but do we need to wait until the 'end' for the outcome and capturing that (feedback). Or can do we this verbally, incrementally (positive impact on quality)? ]

I could ask them all to stand and make like sign-posts, but for the risk of poked eyes. It's true though, sign-posting is an important job, but how we do that is another post (the value of self-discovery as learning).

Once medically fit the key thing should be checking the person's (not viewing them totally as patient) wayfaring skills.

OK, who took my care pathway?

Can they read the map (are they health literate)? Can they find a map? Do they have a stay-well, recovery and well-being ... compass (a conceptual framework, an app, care plan)? If there literally is no self-care pathway under the patient at present, then the student can help them and their carer if necessary to find or create this compass - across the required care domains.

THEN this person (potential future patient) can avoid having to step off their self-care pathway and onto the health care pathway. You see there's a risk and a cost in that particular transfer.




Image source: http://www.farlandgroup.com/customer-journey-mapping/

End of Life Care (Pathways), Nursing and Thresholds

There is a controversy (was in Telegraph) that has been growing for some time, concerning the Liverpool Care Pathway for end of life care. This is a very demanding and yet rewarding aspect of nursing. I have experience of end of life nursing care in a non-specialist capacity, having worked on wards for older adults and being involved with people who have mental health and life-threatening physical health problems.

It pains me greatly not just as a scouser that something with 'Liverpool' in it should become a cause of distress, a center for debate and review. Is the pathway green and shady? Is it comprised of stepping stones, with room for two, and with time granted for your next step? Or is there a danger in some instances the path can become tarmac clad, without the succor of a services stop for basic sustenance? Can a pathway become a motorway? What does that sign say? "DON'T HOG THE MIDDLE LANE!"

What pains me seriously is that what can be a invaluable, evidenced based palliative care resource can be undermined due to the complexity of the generic and palliative care situation.

If we truly practice person-centered care then there are no care pathways.

Or, to put it another way: there are as many care pathways as there are patients and carers.

Whether you believe in social medicine, or private; whether you are laissez-faire, or leave such matters to a higher power there is no escaping the need for organisation - for order.

The mix and concentration of people, knowledge, resources and time dictates that tasks, roles and processes be delineated and assigned. We need to assure a given level of quality, and to predict things, not everything is as difficult as the weather: or death. Pathways can assist in specific contexts.

Is there scope for personalisation on a pathway? ...

Steps and pace can vary and to the left and right of center. There are many pathways though: some valid - evidenced, award winning; while others might be broad, narrow, twisted - to become a disorientating ethical loop...

Being placed on a pathway denotes a decision point, a threshold. We need to remember in all fields of health and social care practice that there are multiple thresholds to be taken into account, communicated effectively and revisited:

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

'me' - existence, resilience, assets, personhood, ethics, personal values, mood, personalised care, understanding of treatment, communication skills, self-expression, loss, orientation, observation, distress, psychological assessment, sedation, beliefs, choices, :theology PURPOSE	'me' - existence, feeding, nutrition, fluids,  evidence base, Liverpool care pathway, quality of life measures, referral thresholds, prediction, resilience, reductive - holistic assessment, medication, distance, where: home-hospital-hospice? pain management, decision locale, specialism, basic nursing care, resilience PROCESS
memories, good-byes, love, compassion, carer under stress, reassurance, counselling skills, meetings with family, empathy and rapport, patient and relative engagement, life history, relative's recognition that loved one is dying, care strategies,  patient experts, patient - carer experience, communities of PRACTICE	consent, advocacy, mental capacity,  integrated working, effectiveness, independent autonomy, service access, bed availability, health & nursing in the media, scope of nursing, scope of medicine, law, medicolegal issues, whistleblowing, complaints, formal review, appeals, organisation, argumentation, professionalism, ageism, POLICY (re-PURPOSED)

The relative position of concepts above does not indicate priority.

"The LCP is not the answer to all our needs for care of the dying but is a step in the right direction."

Marie Curie Palliative Care Institute
Liverpool Care Pathway for the Dying Patient (LCP)

The cost of anholistic care

Being 'holistic' in care delivery can seem anachronistic, paying homage to new age thinking and practices. Paradoxically, being holistic in nursing can also mimic an admin exercise that amounts to ticking the boxes. So for Hodges' model - have you visited all the care domains?

• INTERPERSONAL care ✓
• POLITICAL care ✓
• PHYSICAL care ✓
• SOCIAL care ✓

Advanced discharge planning is many things:

• idealised care;
• standardised care;
• evidence of policy, targets;
• sign posting for the care pathway;
• an essential care aspiration that emphasizes the individual's strengths and resources.

As Wimbledon once again reaches its climax we observe that a fast serve needs to be prepared for a fast return of serve.

Last month 23 June, 2010 The Guardian, Society Guardian featured The high cost of return:

Hospitals could lose up to £1.5bn of NHS funding a year because of the government's decision to penalise those where patients return within 30 days of being treated. That is the conclusion of research conducted by health analysts Dr Foster into the potential impact of the tough new policy. It warns that NHS trusts face large potential losses, the biggest could reach £28.7m, as a result of the new approach. In all, 146 acute, specialist and mental health trusts could lose out. Denis Campbell, p.3.

Apparently -

Andrew Lansley wants to force the NHS to provide better care in hospitals and mental health establishments, to keep treating patients there until they are fit to leave and to work more closely with community-based healthcare professionals, such as GPs and district nurses, to ensure sick people receive more help with their convalescence after discharge and so are less likely to return to hospital. "Making hospitals responsible for a patient's ongoing care after discharge will create more joined-up working between hospitals and community services and may be supported by the developments in re-ablement and post-discharge support," he says.

I hope in reading the above you have a sense of my frustration in that the health career model can encourage and support timely reflection that can help achieve holistic, integrated - coherent care.

If the model was shared
- a common resource -
across disciplines and available to patients and carers
then the potential benefits (and savings?) are even greater.

International Journal of User Driven Healthcare (IJUDH) CfP

Dear Mr. Jones

In view of your work in patient-centered care, I’d like to invite you and/or your colleagues to submit a paper to this Special Issue of the new journal described further below and via the web link provided. I think our global readers would be very interested in your thoughts (and projects) on innovative ways to get relevant healthcare information into the hands of ‘users’ (both patients and providers), within the user-driven EBM paradigm, per below.

Please also share this call for papers with your colleagues.

Thanks for your consideration,

Susan Ross, MD

International Journal of User Driven Healthcare (IJUDH) Call for Papers

Editor-in-Chief:
Rakesh Biswas,
Center for Scientific Research and Development (CSRD),
PCMS Campus, India

Published: Quarterly

Call for Papers - Special Issue:

Submission Due Date: July 1, 2010
Special Issue On User Driven Healthcare and Evidence-based Medicine

Guest Editors:
Susan Ross, MD, FRCPC

Introduction

User Driven Healthcare (UDH) is part consumer-driven healthcare, part narrative medicine, and part Health 2.0. It stems from a concept of participatory healthcare whereby all stakeholders, enabled by information, software, and cyber-community, focus on healthcare value. But where does Evidence-based Medicine (EBM) fit into this framework? It is sometimes forgotten that EBM is a three-legged stool, comprised of the triad of evidence +provider expertise + patient preferences. In this EBM framework, provider expertise is needed to bridge the inferential gap between population-based evidence and the individual patient. And each patient's values and preferences should narrow that inferential gap further. But since the introduction of EBM nearly two decades ago, the primary focus of EBM proponents has been on Evidence, at the expense of patient preferences and provider expertise. Perhaps this is why the promise of EBM to foster the most efficient and high quality healthcare has not yet been realized.

Objective of the Special Issue

This Special Issue will focus on the following questions: Is the recent emergence of User Driven Healthcare really a new, post-EBM paradigm for healthcare, or just an overdue consideration of the other two legs of the original EBM stool? How might this trend affect all stakeholders?

Recommended Topics

Topics to be discussed in this special issue include (but are not limited to) the following:

• Developing valid patient-level evidence using the Web
• Evidence generation—clinical research strategies using social media and mobile technologies
• Examples of UDH to a) help formulate the right questions to ask in EBM; b) develop answers to those questions; c) disseminate the answers to patients and providers with a need to know; and d) test the impact of UDH-generated Evidence on patient outcomes
• Helping online patients sift the ‘wheat’ from the ‘chaff’—information management for patients in an EBM world
• How to incorporate patient preferences and values into ambulatory care decision-making (i.e., into the 10 minute visit)
• Measuring the impact of UDH on patient outcomes
• Patient-level decisions vs. population-level evidence (bridging the inferential gap)
• Pharmaceutical communication strategies using social media—impact on healthcare quality and costs in an EBM framework
• Place of social media in EBM—patient and physician online communities
• Practice of UDH vs. EBM around the world
• Regulatory issues of evidence dissemination by industry using social media in healthcare Statistical and other evaluative methods to assess the validity and reliability of evidence developed using social media and mobile technologies
• Trends in N-of-1 studies, and their relevance to EBM and UDH
• Use of collective intelligence to solve healthcare problems for individuals and communities

Submission

...

All submissions and inquiries should be directed to the attention of:
Susan Ross, MD
Guest Editor

(many) Care Transitions and The Little '-' That Could

Some people looking at Hodges' model may believe that the model perpetuates the dichotomies of old:

Human --- Machine
Individual --- Group
Sick --- Healthy
Supply --- Demand
Home --- Hospital
Self care --- Nursing care

In the 1990s as a community mental health nurse I was involved with a group of general nurses looking at ways of improving:

• discharge planning
• continuity of care

These issues remain and with the dichotomies of care above we can see how Hodges' model can assist our thinking and planning about transition. Not just one transition, but several.

This past week I was fortunate to attend one of a series of workshops -
Delivering High Quality Health Care for All: Bringing the social and technical together for a joined-up approach to deliver supporting systems and technologies
10th/11th December 2009, Leeds, UK

Organised by the UK Faculty of Health Informatics and the BCS Socio-Technical Group

The event was very good, stimulating and challenging. In the closing debate the appeal of 'socio-technical' and how to market a much needed joined-up approach in health IT came down at one point to the difference between:

'socio-technical' and 'sociotechnical'

In trying to find an alternative title, the hyphen was lost, and whilst it is not a crucial issue - for me that hyphen represents the axes of Hodges' model. Hodges' model acts as a high level aide-mémoire and that little hyphen can perform the same trick. The hyphen reminds us of the differences. The dichotomies that need to be navigated and negotiated in our dialogues about care AND caring. These are most evident in transfers and transitions (after all - "getting out of bed is a risk").

There are mini and macro transitions. Care pathways are not yellow-bricked unbroken splines from cottage to cottage hospital. They should be tortured if they do reflect person-centered experiences and needs.

Some transitions are process laden and repetitive, such as drug administration and must be protected - free from interruption. Although grounded in a social exchange of (correct) identities: a registered nurse, the right patient, right drug, right dose, right duration and right time these can be framed within the SCIENCE domain. That is where (for me) the conventional 'drug round' can be found. Counselling is another transition (if effective it also moves people on). 'Counselling' can be found in the INTRAPERSONAL domain - close to the border with SOCIOLOGY.

Other transitions and transfers are more involved:

• person's home to attend day care (for the first time!)
• person's home to residential home
• hospital ward to home
• home encounter with the crisis team
• telecare consultation
• ...

Care is constantly passed hence the need to write and record. Passed from -

person-to-person
team-to-team
team-to-carer
time-to-time
discipline-to-discipline
self-care

This is the outcome that is sought. Ultimately passing responsibility back to the individual and when applicable their family. Having formal integrated care pathways is one thing, but they are never truly continuous, clear and true. And as they say crossing bridges you may have to break step and surely different disciplines march to different tunes? Today though the most audible tune must be socio-technical. ...

Additional link: The Little Engine That Could
Image source:
Drug round tabard http://internet-workwear.co.uk/acatalog/Drug_Round_Tabard.html

Primary Health Care Specialist Group (PHCSG) Summer Conference 2009: Patient Safety – who cares?!

Patient Safety – who cares?!

Primary Health Care Specialist Group (PHCSG) Summer Conference 2009

29th June – 1st July at Chesford Grange Warwickshire

The event attracts a wide group of people including GP’s, other practice staff, nurses and allied health professionals, ICT staff, PCT staff, system suppliers and researchers.

UKCHIP Accredited towards Continued Professional Development (CPD)

Programme and online booking available at http://www.phcsg.org/

Programme Topics include:

• Clinical Risk Management
• Clinical Safety Testing of the Care Record, and Information Governance
• The Future of NHS IT: life after NPfIT in primary care
• Patient Confidentiality – the current legal position
• Practice Accreditation
• Data Extraction from Primary Care Systems (GPES)
• Updates on GP2GP and EPS
• NHS Resources Centre – free training for staff
• Care Pathways- peril or profit?
• Use of Clinical Indications
• Medication Safety Alerts
• RCGP Guide – Making IT work for you

Exhibition - As well as the formal programme the conference provides an excellent opportunity for networking and is supported by an exhibition, which features many of the established IT suppliers to primary care alongside suppliers with exciting new products and services. Come and chat to exhibitors and hear how they are developing and promoting their products or services to enable “Patient Safety”.

Interested in Exhibiting or Sponsorship Opportunities, or need further information?
Contact Jill Riley email jill at phcsg.org