Book: The Unmapped Mind - A Memoir of Neurology, Incurable Disease and Learning How to Live

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INTERPERSONAL : SCIENCES

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SOCIOLOGY : POLITICAL

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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/

Self-care in e-space and the need to Impress

Working with older adults you realise how unselfish a group they are with regards to their care needs: "spend the money on the children who need it, they are the future."

You also realise that although there are growing numbers of 'silver surfers' (sorry) and their number will swell - the use of digital technology by the general public remains yet another potential source of inequality.

Many years ago I came across HealthSpace (UK) as a fledgling approach and application. I was really impressed as it underlined the need for a generic conceptual framework for health and social care - from senior school through to older age.

It is often said that effective communication needs a channel that is noise free - well here in Hodges' model is a resource to reduce noise for health information across many contexts:

• education
• prevention
• consultation
• social marketing
• self-care
• care planning, evaluation and management
• carer support
• supervision

Demographics also underlines the opening remark in this post and for older adults and many younger that matter of choice arises when it comes to the deployment of digital technology. Yes, many forward thinking people will readily jump on board and use ICT to study, learn, commission, record and co-ordinate their own care - or that of a relative. But what about those who will not use HealthSpace or another personal health records [PHRs]?

For those who do not want to engage - are they to be literally pressed into service? Obviously not - and besides recruitment to the UK services is growing. Jokes aside though the pressure to get the public to add value to their own care is critical to the future sustainability of the health and social care system.

Which brings me back to HealthSpace and the following news on e-Health Insider:

'HealthSpace expansion plans shelved'

Last year’s Health Informatics Review outlined a wide-ranging role for HealthSpace, but the DH has now done a U-turn and demanded more evidence of the site’s value to patients before pushing ahead with further expansion.
...
An outline business case worth £80m to £90m – one source puts the figure at £98m - had been developed by CfH, which was to have been submitted to the Treasury earlier this year.

However, the DH is understood to have spiked the business case, seeking more evidence for the value of HealthSpace, which has not received the backing of Christine Connelly, director general of informatics.

Dr Neil Bacon, founder of the doctors’ website doctors.net and the patient website iwantgreatcare.org, said he was unsurprised that the DH had shelved its plans.

“I think this is their way of quietly getting rid of it,” he told EHI Primary Care. “In the commercial world, if a solution with more than 250,000 potential users had only been used by 400 people it would already have been put out of its misery.”

Dr Bacon said he believed there was a clear and growing demand for patients to manage their own health records but that innovative, entrepreneurial solutions rather than government-led solutions would meet that demand.

More to follow no doubt - but do take care even now if you live by the coast ....

Additional links:

Google Health
 
Microsoft - Health

Digital Britain

The Impress Service

The Royal Navy

Image source: Press Gang stamp

Complex signatures

A signature is a very personal thing and has been since writing, power and authority were formalised in pre-printing times. Today with identity theft rampant, effective means of assuring, legitimating and protecting 'signatures' of various forms is a pressing concern.

Signatures matter in health and social care and not just because of individual budgets, but there again....



If an individual is suddenly vested with a budget for personalised care, then what about our expectations of them? What are the expectations of the councils counting pennies length and breadth of the land? The creative use of budgets depends upon self-knowledge, or reliance of the knowledge and experience of others. If things are to change - this requires in the first instance, personal reflection and insight that instils the confidence to take risks, a critical degree of self awareness with a piquant of realism. In the second instance an internet portal, other resources, perhaps a person is needed gifted (indeed) with holistic oversight and awareness of the individual's 4-5 fold unique care signature and local care economy.

Signatures are not new in health care. An effective relapse signature is a difficult and personally costly resource to identify, implement and refine. And yet this invaluable currency facilitates self-care management for many people with mental health problems and long term medical conditions.

Just as our written signatures change as we age, people had better get creative to ensure individuals are equipped and can be equipped with a care signature of their own.

Yours Truly,

Risk: Triangles that Trip [ack. Siegel, HSJ 20 Dec. p.23]

Happy holidays to one and all! Your interest is greatly appreciated.

In last weeks HSJ Matt Siegel's Data Briefing featured 'Missing pieces of the emergency plan', the focus was the risk relative to the population average of emergency admission, outpatient and A&E visits for specific intervention groups.

One of the figures comprised a pyramid which lists the intervention strategies that aim to reduce these service contacts:

CASE
MANAGEMENT
[Very high relative risk]
DISEASE MANAGEMENT [High risk]
SUPPORTED SELF-CARE [Moderate risk]
PREVENTION AND WELLNESS PROMOTION [Low risk]

By pursuing case management of course we can reduce the number of people needing to visit or be admitted to health services. Siegel highlights that if efforts are limited to those at very high risk then we can only influence (at best) 10% of total emergency admissions.

I've been working quite closely with a community matron recently and this 10% are a worthy target, but looking at triangles there are two essential dimensions here. One concerns the 'ascent'. Although it usually takes time (and may even entail oxygen at home) we need to entertain people at base camp for as long as possible. Why?

Because when viewed in terms of the health career every one of us is a climber.

As the supported self-care and prevention labels reveal this is recognised and is very much a part of overall strategy - but; in the low-lands though, the fog can cloud our vision.

The other dimension also lies in the very structure of triangles. The sticky-out-bits: the feet - can trip you up. Siegel points out the need to intervene elsewhere; apparently for example, the two middle risk levels which account for 20% of the total population. In the saga of joined-up health and social care the value of day care for example seems lost in the debate about who/how it should be provided? I need to check the latest literature, but I thought the size and stability of an individual's social network is a key determinant in +ve mental health? Another research question relates to how the number of required day places is derived?

In looking to make changes in the towering heights, let's not forget the nitty-gritty of care on the ground.

It isn't just having these varied intervention programmes in place. It's about managing the traffic on the passes (now there's a subtle interface!). There are many communities out there and they are far from equal. Community care: define. ...

an·a·gram: triangle = alerting, altering, integral, relating

Signatures: Patient* and professional get engaged

These days signatures are a prime time issue.

For personal, professional, business, political and electronic accountability the dotted line in one shape or form still rules. In health and social care there's another signature that contributes to security and certainty: the relapse signature. Whether you see this as stark pessimism or realism there's no doubting its ... erm ... significance.

Relapse is an unfortunate prospect across the care spectrum, but especially for people with severe and enduring mental health problems and those with long-term medical conditions [LTMC]. For these people and their families the risk of relapse is a fact of life. As new health and employment policy encourages people to return to work, employers are affected too.

Health economists and commissioners of care recognise how in the UK of about 17 million people living with LTMC, just 2% of them account for 30% of unplanned hospital admissions. [Carlisle, D. (2006) Predicting the Future, HSJ, 2 Nov. p.24-26] Add to a LTMC a mental health problem (very likely!) and you have a mega care 'transaction' with multiple signatories involved.

If you listen carefully you'll hear the arrows whiz by towards the financial targets that follow.

Hodges' model can help target those arrows and assist with in-flight corrections across the care spectrum, especially when staying-well needs to be emphasised and enhanced. This does not mean you pull a flip chart or laptop from your pocket and commence a presentation on the model. If engagement at this point is rather like paddling up-river, then h2cm can help you navigate and locate the best channel for communication. If family and carers are also on-board that is great. Together, you can map the physical, emotional, social and service aspects of a previous crisis. Alternately, you can anticipate future difficulties in each of the care domains, identify and agree courses of actions and solutions were possible.

Nurses have a penchant for injections and - increasingly - prescribing. There is also the matter of how best to deliver and reinforce social and information prescriptions? So inject some realism by having the participants use their imagination. Given events last year are x and y really likely at 02:30 AM? There are several benefits in using Hodges' model:

• Using the model can help both internalise and externalise problems and solutions -

patient: "This is my fault!"
carer: "I can cope with this myself."

• Formal arrangements, documents and agreements can follow this global yet gentle introduction.
• The model can capture physical signs and symptoms, side-effects, interpersonal and behavioural changes.
• Strengths & Weaknesses: Pros & Cons, Warning Signs.
  
• Outline plans, actions for X,Y,Z ...
• Share expectations.
• Service coverage 24 hours?, alternatives. Respite provision.
  
• This is not about you the professional (or volunteer!) displaying your knowledge, the patient and family are the experts.
• Even though you set boundaries on the session (time, objectives, 'taboo topics - for another time & place' ...), you may be surprised by what the four+ care domains help reveal for future reference and benefit. (This also extends to palliative care, where relatives and carers needs are further emphasised.)
  
• If the patient and family struggle to understand h2cm, don't forget you can still use the model as a guide, an aide mémoire.
• And OK flip chart paper would help! ...
  

Now, if you can please sign here ............................... confirming this message received:
it's over to you - and make that care count!

*And carers too of course.