P3C-OCT: Person Centred Care Organisational Change Tool: Dashboard of Your Results

Transcription

1 P3C-OCT: Person Centred Care Organisational Change Tool: Dashboard of Your Results [1] Your Overall Score [2] Question-by-Question Dashboard [3] P3C Domains Dashboard [4] The Full Results 1 1

2 Number of Practices P3C-OCT Dashboard: Your Overall Score Your score in comparison to other practices Score The graph above shows your total score on the Person Centred Care Organisational Change Tool (P3C-OCT) in comparison to other practices in the SPQS scheme Scores on the P3C-OCT are given out of a total of 20 points All of the 29 main questions of the OCT are weighted equally, and points are allocated equally for: objective activities (e.g. processes you stated you were doing to deliver P3C) subjective responses (e.g. how well you thought these were working) A score of 20 is the theoretical maximum. Such as score is probably not attainable (or desirable), and could only be achieved with: full P3C activity (as measured by the P3C-OCT) all activities subjectively rated as working very well A low relative score does not necessarily indicate poor performance for person centred care instead, it suggests that other organisations responded more positively to the P3C-OCT, which is likely to be related to factors such as organisational size and structure Please see the accompanying P3C-OCT guide for further information about the scoring mechanism Most practices achieve less than half this score, with a median of 6/20* The score of your practice is highlighted in red, in relation to other practices in blue Other charts later in the Dashboard follow an identical format and scoring mechanism, although the axes have been removed to produce minicharts 2 *In new, complex innovations such as P3C, it would be reasonable to initially expect low scores. We are optimistic that these scores will increase in the future, and that the P3C-OCT will also be sensitive to these changes.

3 The Person Centred Coordinated Care - Organisational Change Tool (P3C-OCT) A brief introduction & quick start guide to the dashboard About the P3C-OCT Person Centred Coordinated Care ( P3C ) is our framework for understanding new models of care, which we define as care that is guided by and organised effectively around the needs and preferences of individuals with complex needs. The P3C-OCT is an evidence based measure of progress towards delivering person centred coordinated care from an organisational perspective. This document contains your results from the P3C-OCT, obtained from the answers your organisation gave when responding to the P3C-OCT. Your responses are presented in relation to aggregated results from other practices in the SPQS scheme. We believe that presenting the choices that other organisations have made will help facilitate further improvements in P3C. These results are purely for feed, facilitation and learning. They will not be used for auditing and benchmarking purposes, and will not be shared with anyone else without prior consent. Using the P3C-OCT Dashboard Later in this dashboard, scores for individual questions and domains will be presented in a condensed version of the graph on the previous page, giving an indication of where your practice is in relation to other practices The further to the left the orange bar (your practice) is in relation to the other bars, the worse your practice performed in relation to other practices. These minigraphs are for indicative purposes only, and are intended to provide an at-a-glance indication of your results. These minigraphs can help you to identify areas which areas might be particular strengths or weaknesses, although often the worse performing areas will be factors that are outside of your control (e.g. interoperability and governance; P3C solutions that are not appropriate for your organisational structure) Organisation of the P3C-OCT Dashboard This first section (brown template) provides your overall score and this introductory material. The second section (blue) gives a question-by-question dashboard of the 29 questions. This contains brief descriptions of the questions, with minigraphs to help orientate you to the results. Next, the third section (green) investigates the same data, but instead organises the results according to domains of P3C. In this way, the P3C-OCT is divided and aggregated according to aspects of P3C which are informed by the current policy and research landscape (e.g. National Voices I Statements & House of Care), enabling you to interrogate your organisation across these dimensions. The final section (black) contains your full results and complete responses, in addition to the aggregate results of the other organisation in the SPQS scheme. The P3C-OCT provides a vast wealth of information about what you and other organisations are currently striving to do to implement P3C. We encourage taking the time to interrogate the data, paying particular attention to the responses of other organisations in those domains or questions that you wish to improve. 3

4 OCT Results Overview Part 1: Person-Practitioner Interactions Your scores in relation to other practices Hint: these images always link to the start of each section Link Relative Score Question Summary Link Relative Score Question Summary Q1 Avoiding unnecessary repetition - single contact; plans across/within teams; MDT; discharge Q7 Eliciting goals Q2 Information to empower people Q8 Supporting social goals Q3 Prevalence of co-created care plans Q9a Support tailored to ability/motivation Q4 Elements of care plan Q9b Feed of PAM scores into practice Q5 Leads for care planning/coordination Q10 Consideration of physical/mental health 4 Q6 Support for Shared Decision Making (SDM) Q11 Carer support

5 OCT Results Overview Part 2: Practitioner-Practitioner Interactions Your scores in relation to other practices Link Relative Score Question Summary Q12 Q13 Q14 Q15 Partnerships with other teams MDT Meetings Allocation of roles/responsibilities Who acts on care plans 5

6 OCT Results Overview Part 3: Organisational Systems & Support Your scores in relation to other practices Link Relative Score Question Summary Link Relative Score Question Summary Q16 Q22 Proactive case management Caseload assignment Q17 Q23 Measuring experience of care P3C training/support Q18 Q24 Allocating P3C to people Culture change for P3C Q19 Organising care for those who have P3C Q25 Interventions to reduce hospitalisation Q20 Contacts/appointments for supporting P3C Q26 Polypharmacy/medication review/management 6 Q21 Systems to support/confirm SDM Q27 Other systems to support P3C

7 OCT Results Overview Part 4: Information systems/ IT tools Your scores in relation to other practices Link Relative Score Question Summary Q28 Q29 IT systems for self-care IT systems in place 7

8 OCT Dashboard: By P3C domains On the following pages of the dashboard, we breakdown your OCT scores according to six domains of P3C. Each P3C domain score has a minigraph for that domain, which is presented in relation to other practices in the SPQS scheme. For scoring and axe of these graphs, please refer to page 2 and the P3C-OCT Guide. Below each graph are the P3C-OCT questions that relate to this domain. Clicking on these question numbers will navigate to the results for this question - for both yourself (on the initial question slide) and for other practices (on the subsequent slide). On the following slide, we start with your aggregated results for all six of our Major Domains of P3C. This is followed by a further six slides with each of the major domains divided into sub-domains We recommend that you first identify the domains of P3C which you feel need improving. Next, investigate both the sub-domains and the actual questions that correspond to these domains. 8

9 Major Domains of P3C Your scores in relation to other practices Hint: these boxes are links to explore the sub-domains! My goals Decision Making Care Planning Q2 Q7 Q8 Q9a Q9b Q11 Q28 Q6 Q21 Q1 Q3 Q4 Q5 Q12 Q13 Q14 Q15 Q16 Q18 Q19 Q22 Q25 Q29 Information & Communication Transitions Organisational Process Activities Q1 Q2 Q5 Q12 Q13 Q14 Q1 Q12 Q13 Q14 Q15 Q25 Q10 Q17 Q20 Q23 Q24 Q26 Q27 Q29 9

10 Goal Setting: Sub Domains My goals: Overall Results My goals: Goal Setting My goals: Empowerment & Activation Q2 Q7 Q8 Q9a Q9b Q11 Q28 Q7 Q8 My goals: Self- Management Q2 Q9a Q9b Q28 My goals: Carer Support Q2 Q9a Q9b Q28 Q11 10

11 Decision Making: Sub Domains Decision Making: Overall Results Involvement in decision making Q6 Q21 Q6 Q21 11

12 Care Planning: Sub Domains Care Planning: Overall Results The care plan Case management Q1 Q3 Q4 Q5 Q12 Q13 Q14 Q15 Q16 Q18 Q19 Q22 Q25 Q29 Single point of contact Q3 Q4 Q15 Q29 Care coordination Q12 Q13 Q14 Q16 Q18 Q19 Q22 Supporting people to stay at home Q1 Q5 Q19 Q3 Q5 Q12 Q13 Q25 12 Q14 Q15 Q29

13 Information & Communication: Sub Domains Information & Communication: Overall Results Relational continuity Information gathering/sharing Q1 Q2 Q5 Q12 Q13 Q14 Q5 Q14 Knowledge of patient/familiarity Q1 Q2 Q12 Q13 Q14 Q1 13

14 Transitions: Sub Domains Transitions: Overall Results Continuity of care Q1 Q12 Q13 Q14 Q15 Q25 Q1 Q12 Q13 Q14 Q15 Q25 14

15 Organisational Process Activities: Sub Domains Organisational Process Activities: Overall Results Valuing physical & mental health equally Experience of care Q10 Q17 Q20 Q23 Q24 Q26 Q27 Q29 Q10 Q17 Longer appointment times Staff training Processes to address polypharmacy P3C leadership/ culture change Q20 Q23 Q26 Q23 Q24 Q27 Q29 15

16 P3C-OCT: Full Results of the 29 Questions (a) Your Full Results (b) Aggregated results of all practices The final question contains detailed content for each of the 29 main questions in the P3C-OCT. On the initial page for each question, we provide your full responses to the P3C-OCT that you previously filled in. On the subsequent page, we provide graphs showing the aggregate results of other practices in the SPQS scheme. The P3C-OCT is divided into four sections: Part 1: Person-Practitioner Interactions Part 2: Practitioner-Practitioner Interactions Part 3: Organisational Systems & Support Part 4: Information systems/it tools 16

17 LEVEL 1: Person-Practitioner interactions Q1: What do you do to ensure that a person doesn't have to repeat themselves unnecessarily? (please indicate which processes you have in place and how well you think they are working) Possible Options Answers How is this working? A single person with responsibility for coordinating all care Yes Working well Sharing a plan of care appropriate information within your team Yes Working well Sharing a plan of care appropriate information across teams Yes Requires some improvement A shared care plan document within your team Yes Working well A shared care plan document across teams Yes Requires some improvement MDT Clinical meetings Yes Working very well Discharge planning None Other please specify GP electronic contemporary care record Working very well 17 Your Comments: None

18 Q1. Aggregated results of other organisations. 18

19 Q2. Which of these is available to empower people? Possible Options Answers How is this working? Providing information sheets Yes Working very well Signposting to the 3rd sector Yes Working well Referrals to other services Yes Working very well Referrals to peer support groups Yes Working well Pharmaceutical support Yes Working well Other please specify 19 Your Comments: None

20 Q2. Aggregated results of other organisations. 20

21 Q3a. Do all people who could benefit for P3C have a co-created single personalised care plan in the form of a written document? Q3b. Are they given a copy of their care plan? Possible Options Within teams Across teams Answers A few A few If no why not 3b Are they given a copy of their care plan Yes 21

22 Q3a & Q3b Aggregated results of other organisations 22

23 Q4. In general, which of the following elements are included in the cocreated plan of care (this can either be in the form of a written document or a plan of working)? Possible Options A lead coordinator A contingency plan for crisis episodes or exacerbations of their condition A named person to contact in a crisis Answers Yes Yes Yes An action plan to attain their health goals An action plan to attain their social goals Details of who is responsible for what A List of medications and instructions for when to take A date for review Treatment Escalation Plan Yes None Not relevant Other please specify How well are your care plans working Requires some improvement 23 Your Comments: None

24 Q4. Aggregated results of other organisations. 24

25 Q5. Who normally takes the lead for care planning/ care coordination? Please tick as many as appropriate. Possible Options Managerial lead Answers Clinical lead Team coordinator GP District Community Nurse Yes Community Matron Community Therapy teams Social workers Care workers None Not relevant Other please specity If dual lead please specify How well is this working Working very well 25 Your Comments: None

26 Q5. Aggregated results of other organisations. 26

27 Q6. How is shared decision making with individuals supported in your organisation? Possible Options Individual and practitioner work together to set goals Answers Yes Longer appointment times Decision aids Information sheets Yes Measurements of patient experience of shared decision making Personal budgets None Yes Not relevant Other please specify How well is shared decision making working in general in your organisation Requires some improvement 27 Your Comments: Currently only benefits a few patients.

28 Q6. Aggregated results of other organisations. 28

29 Q7. How do practitioners specifically elicit goals related to people's health and social aims? Possible Options Answers How is this working? Personalised care plans structured around the identification of goals None Not relevant Goals prompted in a separate section of the written personalised care plan None Not relevant Some practitioners trained to provide guided conversations None Not relevant Longer appointment times None Not relevant Using best interest e g Power of Attorney or formal Yes advocate Working well Other please specify Not relevant 29 Your Comments: None

30 Q7. Aggregated results of other organisations. 30

31 Q8. How do practitioners ensure that people are supported to achieve their individualised social goals? Possible Options Answers How is this working? Conversations with the individual to review goal achievement Yes Working well The auditing of the plan of care Yes Working well The use of additional support for example health trainers peer support coaching advocacy services or Yes Working well the voluntary sector The use of tools to help people track whether they are achieving their goals for example a diary checklist charting changes such as weight health apps None Not relevant Other please specify Not relevant 31 Your Comments: None

32 Q8. Aggregated results of other organisations. 32

33 Q9a. How is support tailored to the person's ability and motivation to manage their own health? Possible Options Answers How is this working? Use of a patient measure of activation e g PAM Yes Not relevant Use of activation measure score as part of the care planning process None Not relevant Health coaching to support self management Yes Working well Peer to peer support Yes Working well Group based training for self management Yes Working well Disease specific training Yes Not relevant Other please specify Via health connection mendip Not relevant 33 Your Comments: None

34 Q9a. Aggregated results of other organisations. 34

35 Q9b. How are self-management scores (e.g. PAM) fed into practice? Possible Options Answers How is this working? Gathered externally and never included in records None Not relevant Gathered externally and included in records but rarely used None Not relevant Used informally in care planning None Not relevant Structured within the care plan None Not relevant Other please specify 35 Your Comments: None

36 Q9b. Aggregated results of other organisations. 36

37 Q10. In what ways is consideration routinely given to understand how mental wellbeing affects peoples physical conditions, and of the role of physical wellbeing on mental health? Possible Options Answers How is this working? Through Longer appointment times Yes Requires some improvement Personalised care plans structured to address this None Not relevant Mental health workers link into the team None Not relevant Other please specify Not relevant 37 Your Comments: None

38 Q10. Aggregated results of other organisations. 38

39 Q11. How are informal carers assessed and offered support? Possible Options Answers How is this working? Identification of the carer population Yes Working very well Carer health and wellbeing assessment None Not relevant Providing advice and signposting to support services Yes Working very well Provision of respite if required None Not relevant Other please specify Not relevant 39 Your Comments: None

40 Q11. Aggregated results of other organisations. 40

41 LEVEL 2: Practitioner-Practitioner interactions Q12. With what other teams do you have agreements in place to enable partnership working and provide joined up care? Possible Options Answers How is this working? Community based hub or team specialising in LTCs Not Relevant General practice Yes Working very well Nursing specialists e g District Nurses Community Yes Matrons Working well Mental Health services Yes Requires some improvement Community Therapy teams Yes Requires significant improvement Paid care providers e g care agencies Not Relevant Voluntary sector providers Social Work teams Emergency Department Not Relevant Not Relevant Not Relevant Community based admission avoidance teams Yes Working well Intermediate care team Residential care home providers Other please specify Not Relevant Not Relevant Not Relevant 41 Your Comments: None

42 Q12. Aggregated results of other organisations. 42

43 Q13. Do multi-disciplinary team meetings take place to identify the most appropriate services and interventions for people suitable for P3C? Question Possible Options Answers Do meetings take place How often to these MDT meetings happen Yes Monthly Other please specify How well are your multi disciplinary team meetings working Requires some improvement Who attends these meetings Practice nurses Yes District nurses Community Matrons Mental health services Acute care providers Social workers Care workers Voluntary sector e g Age UK Physiotherapists Occupational Therapists Pharmacist Medical Consultant Other please specify None Not relevant Other please specify 43

44 Q13. Aggregated results of other organisations. 44

45 Q14. Are processes in place to allocate roles and responsibilities across and within teams? Question Possible Options Answers How well is this working? 14 Are processes in place to allocate roles and responsibilities across and Yes within teams Please identify from below Processes in place for a single named person coordinating the support and care of each person suitable for P3C Yes Working well WITHIN teams Processes in place for a single named person coordinating the support and care of each person suitable for P3C Not Relevant ACROSS teams Across team agreements to work together on a single care plan Not Relevant Processes in place to ensure continuity of care care transitions please specify Yes Not Relevant in the comments box below Processes in place for active Mental Health Team input Not Relevant None Not relevant Other please specify Not Relevant Comments 45

46 Q14. Aggregated results of other organisations. 46

47 Q15. Which practitioners act according to the personalised care plan? Possible Options GP Answers Yes District Community Nurse Community Matron Mental Health Team Social Workers Care workers e g agency workers Nominated 3rd sector providers Yes Physiotherapists Occupational therapists Consultant Specialists Other please specify Plans are used but not personalised Plans are not used Not relevant Other please specify 47 How well is this working Your Comments: None Working well

48 Q15. Aggregated results of other organisations. 48

49 Level 3: Organisational Systems and Support: Q16. How do you provide proactive case management (identification, assessment, planning, monitoring and coordination)? Possible Options Answers How is this working? Use of predictive models to identify who will benefit Yes from P3C Working very well Appointments are available for crisis care Yes Working well Appointments are available for proactive care Yes Working very well Multi Disciplinary Team MDT meetings to discuss Yes complex cases Working well Systematic review of caseload list Yes Working well Allocation of an individual from MDT with responsibility to ensure ongoing care Not relevant Not relevant Other please specify Not relevant 49 Your Comments: None

50 Q16. Aggregated results of other organisations. 50

51 Q17a. For which groups do you measure the experience of care: Possible Options Answers How is this working? People suitable for P3C None Not relevant Families of individuals suitable for P3C None Not relevant Carers of individuals suitable for P3C None Not relevant Other please specify Not relevant 51 Your Comments: None

52 Q17. Aggregated results of other organisations. 52

53 Q18. What systems are in place to identify and allocate people suitable for P3C? Possible Options Answers How is this working? Risk stratification and automatic allocation None Not relevant Risk stratification and allocation by team agreement None Not relevant Agreement by team providing P3C Yes Working well Routine discharge screening None Not relevant Ad hoc clinical complexity identified by practitioner Yes Working well External practitioners services refer in None Not relevant Other please specify Not relevant 53 Your Comments: None 17b. How do you use the measures from Q17a to inform the delivery of care/ support?

54 Q18. Aggregated results of other organisations. 54

55 Q19. Which approaches are used to organise the care of those identified for P3C? Possible Options Answers How is this working? A lead practitioner takes on case management role for each individual Yes Working very well People s needs and treatment are reviewed regularly Yes Working very well The need to step up down intensity of input reviewed regularly Yes Working very well MDT meetings Yes Working very well Regular review of case load allocation Yes Working very well Other please specify Not relevant 55 Your Comments: None

56 Q19. Aggregated results of other organisations. 56

57 Q20. What contact/ appointment arrangements are in place to support P3C? Possible Options Answers How is this working? Appointments specifically for P3C planning None Not relevant Longer appointments available on request for routine None care Not relevant Home visits for P3C planning Yes Requires some improvement Other please specify Not relevant 57 Your Comments: None

58 Q20. Aggregated results of other organisations. 58

59 Q21. What systems are in place to support and confirm thatshared decision making has been implemented? Question Possible Options Answers 21 What systems are in place to support and confirm Care record audit that shared decision making has been implemented Using a questionnaire tool to elicit people s experiences please specify which measure None Not relevant Yes If using a questionnaire tool to elicit people s experiences please specify which measure To what degree is this information fed into practice Other please specify Comments for example which aspects are working particularly well not well Not working Ticked not working but above says none so should be a not relevant to select 59

60 Q21. Aggregated results of other organisations. 60

61 Q22. How are caseloads assigned to the following teams? Possible Options Answers How is this working? Nursing specialists None Not Relevant Mental health services None Not Relevant Care providers e g agency workers None Not Relevant Social workers None Not Relevant Community therapy teams None Not Relevant Other please specify below None Not Relevant Name of other team s if any 61 Your Comments: None

62 Q22. Aggregated results of other organisations. 62

63 Q23. Are there ongoing efforts to ensure that support and training for staff in P3C continues to be developed in the following areas? Possible Options Answers How well is this working? Person centeredness Yes Requires some improvement Self management None Not Relevant Empowering and activating individuals to be involved in self care None Not Relevant Coordinating care across teams None Not Relevant Health coaching None Not Relevant Shared decision making None Not Relevant Supporting health promoting behaviours None Not Relevant Managing polypharmacy None Not Relevant Decision making in multimorbidity None Not Relevant Promoting managed risk taking for individuals None Not Relevant Other please specify Not Relevant Comments Much of this is normal general practice done by GPs 63

64 Q23. Aggregated results of other organisations. 64

65 Q24. Which of the following activities/ resources are supporting culture change for P3C? Possible Options Answers How is this working? Change Champions for P3C Yes Requires some improvement Formal bench marking eg reviewing performance indicators such as number of personalised care plans None against internal performance or external Not relevant organisations Informal bench marking eg group reflections on practice None Not relevant Auditing P3C activities None Not relevant Other please specify Not relevant 65 Your Comments: Change Champions for PCCC - improvement = time

66 Q24. Aggregated results of other organisations. 66

67 Q25. What interventions are in place to reduce unplanned or inappropriate emergency admissions? Possible Options Answers How well is this working? Predictive modelling to identify people most at risk Yes Requires significant improvement Support to increase self management skills during crisis e g medication help seeking Yes Requires some improvement Telemedicine providing remote clinical services to patients via communications technologies Yes Requires some improvement Hospital at home service intensive community based None treatment Use of virtual ward None Coordinated working between health and social care None e g joint assessments Ward based health and social care coordinators to Not relevant support discharge Individualised discharge plans Implementation of specialist support Services e g intermediate complex care teams please specify Advanced planning e g Treatment Escalation plans TEP Lasting Power of Attorney LPA Community rehab therapy teams Open Ended Response Type of Specialist support service if applicable Comments Not relevant None Yes None Requires some improvement 67

68 Q25. Aggregated results of other organisations. 68

69 Q26. What procedures are in place to address polypharmacy/ review medication management? Possible Options Answers How is this working? Pharmacist attending MDT meeting Yes Requires some improvement Pharmacist review for some or all patients Yes Requires some improvement Questions prompts about medicine taking for patients during reviews Yes Working well Routine face to face medicine reviews Yes Requires some improvement Training for patients in medicine optimisation No Not relevant Medicine audit Yes Working well Other please specify Not relevant 69 Your Comments: None

70 Q26. Aggregated results of other organisations. 70

71 Q27. What other systems are in place to support P3C? Possible Options Answers How is this working? The pooling of budgets to be used flexibly by teams Use of tools and care plans to identify missing pathways Measurement of staff experience of P3C Paper based directory of services None None None None Other please specify 71 Your Comments: None

72 Q27. Aggregated results of other organisations. 72

73 Q28. What kind of promotion is there to support self-care? Possible Options Answers How is this working? Telecare No Not relevant Telemedicine Yes Requires some improvement Telecoaching No Not relevant Other please specify Not relevant 73 Your Comments: None

74 Q28. Aggregated results of other organisations. 74

75 Q29. Which of the following IT based systems are in place? Possible Options Answers How well is this working? A template record keeping system to bring together Yes a single care plan within your team Working very well A template record keeping system to bring together a single care plan which is shared across organisations None N A Electronic health social care plans accessible across None team boundaries in real time N A An electronic directory of services None N A Individuals routinely have access to care plan records Yes Requires some improvement Individuals can add to their electronic care plan record None N A Other please specify Across team agreements to access people s records Across some teams Across team agreements to add to people s records Across some teams Requires some improvement Across team agreements to inform others of changes None Requires significant improvement to people s records Comments 75

76 Q29. Aggregated results of other organisations. 76