Nhs Highland Vision: the Generic Model of Care

NHS HIGHLAND VISION: THE GENERIC MODEL OF CARE

7 SEPTEMBER 2010

The Generic Model of Care will underpin the NHS Vision Statement to provide high quality, effective and sustainable patient centred services appropriate to the needs of patients in a consistent way across NHS Highland. ‘Better Health, Better Care and Better Value’ will result in quality of care to every patient every time. The NHS Highland Quality & Patient Framework will be the essential foundation stone. There will be continuous improvement in quality of care and outcomes, with much more emphasis on supporting patients and their carers to maintain and sustain their own health. Where care is required, this will be provided as locally as possible and care needs will be anticipated as much as possible and therefore more become planned. Unplanned or emergency admissions will, in some cases, be regarded as a failure of the system.

The actual model of delivering the health care element is not radically different from the current existing traditional model, and is still based on the patient/health carer relationship. Traditionally this was the doctor/patient relationship and more recently expanded to the patient/health carer relationship. It is still fundamentally based on the assessment of the patients’ condition, examination, investigation, diagnosis and the provision of appropriate treatment and management.

The fundamental change will firstly be the great emphasis placed on the philosophy of patient self care and responsibility.

Secondly, for those patients requiring care an explicit health management plan will be developed and this will be readily available and accessible to all those involved in care, including the patients and carers. Currently the scheduled and unscheduled (emergency) care of patients significantly involves those patients with a pre-existing known condition. The basis of the Model of Care will be a Long Term Condition Care Management Plan, and for appropriate patients an Anticipatory Care Plan, with an Alert system identified [ACPA].

Thirdly, the care provided will be based on the identified needs of the patients and this care will follow agreed pathways of care.

The implementation will involve rollout of this concept across the whole of NHS Highland and will have a radical effect. There are already innovative approaches to healthcare across parts of NHS Highland and the role out of these will ensure that these are applied to patients across the whole of Highland in a consistent fashion.

The Scottish Government Health Department Policy “Better Health, Better Care” (2007) suggested that ‘health services have to change if they are to keep pace with population trends, patient needs and medical advances’. Table 1 compares the traditional view of care to the newly evolving approach to care.

Table 1.

Traditional View / Evolving Model
Geared towards Acute Conditions
Hospital centred
Doctor Dependant
Episodic Care
Disjointed Care
Reactive Care
Patient as a Passive Recipient
Self Care Infrequent
Undervalued Carers
Low Tec / Geared towards Long Term Conditions
Embedded in Community
Team Based Approach
Continuous Care
Integrated/Holistic Care
Pro-active and Anticipatory Care
Patient as a Real Partner
Self Care Encouraged & Facilitated
Carers Supported as Partners
High Tec

The traditional Model of Care is provided by a number of distinct and discreet Healthcare Providers in different sectors across the organisation, as identified in Figure 1 below.

Figure 1: Sectors of Care.

While the patient appears at the centre of care, services have often been developed to meet the needs of the service providers. Previously there has been little emphasis placed on patient and/or care or self-care to maintain and develop health. There are real boundaries and barriers between GP Practices, Community Health Services, Contractor Services, Local Authority Care and the hospital based Specialist Services.

These traditional sectors have differences in training and expertise, objectives and expectations, funding and management/accountability processes and care is accessed differently. As there is no single and integrated IT system across the NHS, effective communication is difficult. NHS Highland services do not easily translate into a seamless Model of Care for the patient. The new proposed Model of Care ensures that the barriers between the different sectors are removed and patients will flow between different parts of an integrated system, as identified in Figure 2 overleaf.

Figure 2: The Generic Model of Care.

The approach is to reduce the barriers between the providers along the spectrum of care, so that the patient experience is seamless and transition of care from one sector to another is smooth, consistent and continuous.

Patient self-care

Community Based Care by different providers

Hospital Based Specialist and Tertiary Care

Patient Focussed Care will mean more emphasis on the patient and carer taking responsibility for their own health and care, having more knowledge and support to ensure that this happens. The ‘expert patient’ will understand their base line health status and be more aware of when to seek or initiate appropriate increased healthcare.

For the patient with an LTC or ongoing healthcare need, there will an Anticipatory Care Plan [ACP] and an Anticipatory Care Plan Alert [ACPA], which will be available to all involved in their care. These will identify the person’s base line condition and disease status, what changes a patient can and should make, ascertains when to seek additional advice and care, and what criteria may lead to accessing Specialist Care in both the scheduled and unscheduled situation.

Care in the Community Setting is the next level of care provided in the local setting. The providers of this care are the GP and Practice, Contractor Services (including Dentists, Pharmacists, and Optometrists etc.), Community Health Services (Nursing, Midwifery, AHPs) and Local Authority Services.

The concept of developing multidisciplinary working in the Extended Primary Care Team, whether real of virtual, will facilitate seamless and integrated care. This care will be provided in a range of settings within the home and community and the types of care have been identified in Figure 2.

Care in the Specialist or Secondary/Tertiary Care Setting is also identified in Figure 2 and more Specialist Care will be provided out of the traditional hospital setting, within a more multidisciplinary local approach. A fundamental concept to underpin the Generic Model of Care is the development of agreed Conditions Specific Management Pathways, which will identify the:

• Natural history and progression of the disease or condition.
• The role of patient self-care and management.
• The role of health care professionals in supporting self-care and self-management.
• Method of assessment of the condition, current appropriate investigation, diagnosis, management, treatment, maintenance, discharge and follow up, throughout the spectrum of care for that condition.
• Criteria for escalation and management of progressing and complex disease.
• Aspects of Specialist Care.
• Discharge planning.

Within the Generic Model of Care, there will be a number of ‘Modules of Care’ as identified in Figure 3 below, which will be developed for different types of conditions and care. Within these developed modules, the range and types of care and management from patient’s self-care through to complex Specialist and Tertiary care will be identified, so that the patient escalation along the care pathway is quite explicit.

This will result in a clear Framework of Care for NHS Highland identifying what patients are being treated for what conditions, by specified providers at each and every location.

Figure 3: Modules of Care.

Figure 4: Triangle of Care

If the Triangle of Care for a Long Term Condition with Anticipatory Care needs is considered, as identified in Figure 4, then a respiratory disease such as Chronic Obstructive Airways Disease (know as COPD) or Asthma will clearly illustrate the pathway. Guided by the Condition Specific Care Pathway, the patient experience for COPD or Asthma would be as follows:

Patient Self Care would mean that the patient with or without their carer would have a good knowledge and working expertise of their asthma or COPD. The disease and progression would be articulated in the ACPA. The patient and carer would know what their normal disease status would be in terms of i.e. general wellbeing, exercise tolerance, sleep pattern, cough, wheeze, breathlessness, sputum production, spirometry assessment and other various signs. Self assessment would be regularly carried out and enable the patient to self monitor their progress. Coincidentally these assessments would be relayed to the local LTC carer, usually a LTC trained nurse, who would monitor trends over time, the frequency of monitoring being dependant on the severity of the condition. An ACPA would have been agreed and baseline care documented, and also what patient treatment should change if the condition deteriorated slightly. If the assessments indicated a significant deterioration either the patient would manage as previously agreed, with augmented treatment such as antibiotic therapy, steroid therapy or oxygen. The frequency of the self reported assessment would be increased and early intervention would result. The LTC Local Nurse would be aware of the disease deterioration and would increase support either by indirect contact (telephone/VC) or a direct patient face-to-face review. The ACPA would have identified trigger alerts for the escalation of care and access to augmented Primary or Secondary Care Services, as appropriate.

If resolution of the episode of disease deterioration did not occur, then the ACPA would detail what subsequent management or treatment should occur and a review could take place either by the Primary Healthcare Team or a Specialist. This review could take place by a Specialist in consultation from a distance by telephone or VC, in conjunction with the LTC Local Nurse or the Primary Health Team. Subsequently if the episode of care deteriorated significantly, then the patient could be seen by a Specialist in a virtual community ward, at an outpatient clinic or as an inpatient within the hospital, and this would follow the specific criteria laid out in the ACPA. With this system, the Specialist will have had access to the deteriorating episode of care with all the assessments and subsequent changes in management documented, and therefore Anticipatory Care would ensue. The emergency consultation or admission would be averted and hopefully any admission relatively well planned, along the lines identified within the ACPA. Appropriate care would have been instigated at an early stage following early assessment and alerts. All details of agreed care will be included such as DNAR, palliation and the discharge planning process will already have been discussed and documented, and therefore if the patient is admitted to hospital, the planned discharge process will result in a more effective discharge resulting in shorter lengths of stay and improved continuity of care within the community setting.

Pilots of this process have already been implemented such as within Argyll & Bute for patients with COPD and the Nairn Long Term Conditions Project. These projects have been evaluated and have shown an increased quality of care, reduced emergency admissions, a shorter length of stay, a more efficient discharge planning process, and the patients have been able to be maintained appropriately within the community setting for a longer time period.

The Condition Specific Care Pathway would be developed identifying the natural history of the disease, how to manage deterioration of that episode across the escalating pathway of care in terms of assessment, diagnosis, treatment, referral and maintenance. This modular approach is therefore applicable to most types of care.

This Model of Care is not in itself a radical change, but the implications imply:

1. The needs of patients will be responded to in a consistent and holistic fashion, as opposed to being influenced by the wants and demands of patients and staff.
   
2. Services will be re-configured and re-designed to meet the needs of patients as quickly and locally as possible, but the implementation will be consistent across NHS Highland.
   
3. Care will be provided by agreed pathways of care, so that care will be consistent across NHS Highland, with duplication and inefficiencies avoided and a reduction in any identified variation.

1. Outcomes of care will be robustly monitored to ensure compliance and accountability to the care pathways and that high quality of care is being provided.

1. There will be an organisational consensus approach to care management by all involved partners including the patient, health care, local authority, voluntary sector and all other stakeholders.

1. Health carers will be required to adapt to new and innovative ways of working across traditional boundaries of care to ensure a seamless, integrated approach as locally provided as possible.

1. Technologies will support this shift in care.

1. Using the agreed care pathways, criteria for referral and an increased day care/day case approach will result in a requirement for fewer beds in different locations in NHS Highland.
   
2. Implementation will be developed across the whole of NHS Highland, so that everyone will know what care will be delivered to which patients, by whom, where and the point of access to care will be clear. This will result in a clearly identified clinical framework.
   
3. Implementation will be lead by both clinicians and patients, for clinicians and patients. The Board will establish a Clinical Board to guide this.

What Developments Are Now Required:

1. Fully develop the concept of Long Term Condition Management as a fundamental cornerstone of providing care in NHS Highland.

1. Extend Anticipatory Care Plan and Alerts (ACPA) to cover all Long Term Conditions and patients with ongoing healthcare needs, and perhaps consider for all those patients in the over 75 year old age group.

1. Develop agreed Integrated Pathways of Care and Management for common conditions.
   
2. Develop conditions specific referral criteria and a Triage Referral Management System.
   
3. Build a rehabilitation approach and capacity into services.

1. Develop real integrated and multidisciplinary Extended Primary Healthcare Teams including all partners in care.

1. Implement robust audit, monitoring and clinical governance of all care provision throughout NHS Highland.

1. Develop integrated IT Systems with easy access to all involved in care to provide a comprehensive and timely common record.

1. Training of locally based generic staff by more specialist experts to ensure appropriate skills and competence.

1. Staff working practices will be different as there will be fewer direct patient contacts, more generic training for staff, and an increase in multidisciplinary joint care sessions, as well as an increased utilisation of tele/eHealth, especially for consultation and advice. This will inevitably impact on the working practices of all staff and have an effect on the job planning process for all staff.