Experience During the Year of Care Project

Outcomes Framework for Care Planning

Everyone involved in care planning will want to know they are getting the most benefits or doing a good job. But care planning has many component parts (summarised in the Year of Care ‘house’) all of which are important to achieve good outcomes. Some of these are not easily ‘countable’ or measurable on a routine basis. So Year of Care emphasises the importance of developing a ‘ learning’ or ‘reflecting’ organisation in which routine data fields are set up to record what is important as well as what is easy to measure, and teams develop audit and evaluations ‘frameworks’ that suit their circumstances and address the particular issues they are reviewing.

Experience during the Year of care Project.

A traditional evaluation ran alongside the YOC pilot project. This collected large volumes of questionnaire data on service availability, use and satisfaction as well as experience of the clinical encounter and health status.

The lessons learned were that such quantities of data cannot be collected routinely as the volumes overload both the service users and the service itself. Each component also needs to be closely targeted on a particular feature of the care planning process it is trying to assess.

Local targeting collections proved much more useful to the sites in terms of improving their structure, processes and immediate outcomes. For instance interviewing staff and patients immediately after their care planning consultation on the experience of receiving their results gave an early indication of its usefulness; and a facilitated discussion using the PCRS-UK tool enabled practices to reflect on their support for patients and on their internal processes, as well as seeing improvement year on year.

Each pilot site developed slightly different approaches to commissioning care planning using Local Enhanced Service agreements (LES). These contained indicators of structure and process of care planning. Most stipulated key components of the ‘internal practice pathway’ expected, and set up fields to record test results sent to patients (proxy for receiving them), and the presence of patient goals and action plans within the routine record. Some stipulated that sample care plans should be submitted for peer or other review.

Working with other organisations

The YOC programme worked with the RCGP to develop a guide to care planning for practitioners ‘Care planning – Improving the lives of people with long term conditions’. This includes a comprehensive measurement framework and references to the many useful tools available to support all parts of the process. The aim was for a practice to be able to answer the following questions:

• How will we know how we are doing? How can we do better?
• How can we improve out care planning skills?
• How successful is our practice at enabling people to self mange effectively?
• How can we monitor our attitudes and our processes?

The YOC programme also contributed to the work at the Department of Health to develop a ‘single’ measure or set of PROMS that could be used to measure the quality of care for people with LTCs on a national basis. This work is continuing, but YOC has ensured that the potential national metrics are included here.

The Year of Care Outcomes Framework

This learning has been collated in the following Framework which is far from comprehensive but includes the key components that the Programme identified as being important. It highlights (in red) examples of structure, service monitoring and outcomes from which a service could select, and which could be introduced relatively easily by a clinic or practice as they get going. It includes traditional biomedical outcomes, but with the reminder that improvements in these are unlikely to occur until care planning has been established for 3 – 5 years. It is important to embed robust and sustainable processes if the long term clinical benefits that the evidence predicts are going to be achieved.

A list with web links of specific tools, questionnaires and sample competency frameworks etc is provided as an appendix

Glossary of the acronyms used in the Framework:

CQI: Consultation Quality Index

PPiC : Patient Partnership in Care

PCRS-UK: Primary Care Resources and Support

PAM: Patient Activation Measure

LTC 6: Long Term conditions 6

LWYLTC-Patient Survey: Living with your Long Term Condition

HCCQ: Health Care Climate Questionnaire

Component / Service monitoring / Outcome indicators
STRUCTURE: / *Register of population identified for care planning / *Denominator for service monitoring / NB (short, medium and long term): of the whole service – individual components cannot link across.
Resource use:

• Drugs (desired outcome maybe either an increase or decrease)
• Traditional community services (desired outcome may be either or decrease)
• Non traditional community services (desired outcome – increase)
• DNAs for each service component
• Emergencies service use
• Outpatient use
• Inpatients use

*Being an effective self manager

• % of people who say they are confident to manage their own health (Clinic exit question)
• Or Patient Activation Measure (PAM)

Lifestyle choices
Clinical outcomes

• Biomedical (intermediate and final)
• Quality of life (diabetes specific)
• Health status (EQ5D)

Prepared team (with) *clinical lead
*A clinic/ practice care planning ‘pathway’ , with roles identified – and audit framework / *Written evidence, including annual review of staff and practice costs
Trained staff (new and in post) / *Audit of competencies / training attended
IT including key components in place / Availability
Menu of services for Support for Self Management / Availability and up to date
Practice plan for audit , monitoring, reflection and improvement (Including records and care plans review ) / *Available
PROCESS: / % of the registered population who…..
Preparing for the consultation / Information about new service / new to service provided / Received / understood information
*Tests results to person with diabetes before CP consultation / *Received results ( Results sent out -proxy for a newly developing service )
Evidence of meaningful reflection on test results
Quality of the consultation: /

• Jointly reviewing person’s concerns, priorities and agenda setting
• *Goal setting and action planning

/

• *Systematic recording of goals and action plans in language that implies ownership of person with diabetes
• *% who feel supported to manage their condition - clinic exit question (currently in national GP survey and NHS Outcomes Framework ; 2011-2012)
• % completing all or part of CQI or PPiC or LTC 6 or LWYLTC or HCCQ

Individualised follow up arrangements / Record
After the consultation: / *Summary ‘care plan’ available for the person / * Written summary (care plan)
Follow up arranged : goals and action plans reviewed / Evidence in records
OVERALL SERVICE: / ‘Patient satisfaction’/‘Patient experience’
Practice support for self management (PCRS-UK)

Outcomes Framework for Care planning for a practice or other clinical team: linking the organisation, clinicalbehaviour and outcomes

Summary of Evaluation

Questionnaire / What it measures / How to obtain it / Other information
PPiC : Patient Partnership in Care / 16 questions to be completed by the patient following an individual consultation
It focuses on partnership working and support for self management / Only available under licence but can be viewed from the following sources:
Powell, R. Powell, H. Baker, L. & Greco, M. (2009) Patient Partnership in Care: A new instrument for measuring patient–professional partnership in the treatment of long-term conditions. Journal of Management & Marketing in Healthcare. Vol. 2 No. 4. PP 325–342. / This questionnaire would need to be applied and paid for
PCRS-UK: Primary Care Resources and Support / Individual practitioners complete this questionnaire independently. It consists of 16 questions relating to support for self management under patient and organisational headings / Availability for use and instructions for downloading it can be found at: / Available free of charge but the site requests you inform them if you plan to utilise this in order to allow them to track its use
EQ5D / EQ-5D™ is a short questionnaire that patients can use to rate their health status. / Only available under licence but can be viewed from the following sources:
/ A fee will be charged for use of this questionnaire- this will be calculated after registration and will depend on a number of factors listed on web link
PAM: Patient Activation Measure / This tool can be used to measure patient activation at both an individual patient basis (to diagnose activation and individualise care plans) and to compare the efficacy of interventions such as Care planning. / Only available under licence but can be viewed from the following sources:
Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in patients and consumers. Health Services Research 2004: 39:1005-1026. / This questionnaire would need to be applied and paid for
Long Term Conditions 6 (LTC 6) (part of the QIPP programme) / 6 brief tick questions for patients to complete following a consultation covering areas including involvement, support and confidence / See appendices
Living with your Long Term Condition (LWYLTC) Patient Survey / 33 tick box questions for patients to complete following a consultation-
Areas covered include ability to cope, consultation skills of the practitioner from this visit and views on visits over the last 12 months , ability to self care, basic demographics including identification of LTC / See appendices / Some of the wording would need to be modified – i.e. site , who is performing the survey,
CQI (Consultation Quality Index) - version adapted for Diabetes / 18 tick box questions for patients to complete following a consultation (some of which are extracted from LWYLTC) and therefore cover similar themes
Focuses on ability of the patient to cope and self manage with diabetes , and consultation skills related to care planning / See appendices / CQI instructions and results template available from the Year of Care National Programme
Health Care Climate Questionnaire (HCCQ) / 15 scaled questions rating the clinicians style of consultation / See appendices
Team Climate Questionnaire (TCQ) / Aims to help teams develop a shared description of their work environment - it focuses on the openness and collaboration within a team / See appendices / 3 options for this questionnaire
Care planning checklist and Audit tool summary / A checklist of processes for setting up and monitoring of Care Planning within an individual practice / See appendices / Produced by Year of Care Programme

Appendices with available evaluation questionnaires

Long Term Condition 6 (LTC 6)

LTC -6

Please think about the last 12 months, when you received care and support for your condition(s)…

Please tick one box for each statement and answer every statement:

a.Did you discuss what was most important for you in managing your own health?

Not at all /  / Rarely /  / Some of
the time /  / Almost always / 

b.Were you involved as much as you wanted to be in decisions about your care or treatment?

Not at all /  / To some extent /  / More often than not /  / Almost always / 

c.How would you describe the amount of information you received to help you to manage your health?

I didn’t receive any information /  / I rarely received enough information /  / I sometimes received enough information /  / I always received the right amount of information / 

d.Have you had enough support from your health and social care team to help you to manage your health?

I have had no support /  / I have not had enough support /  / I have sometimes felt supported /  / I have always felt supported / 

e.Do you think the support and care you receive is joined-up and working for you?

Never /  / Rarely /  / Sometimes /  / Always / 
Not at all
confident /  / Not very confident /  / Somewhat confident /  / Very confident / 

f.How confident are you that you can manage your own health?

Living With Your Long Term Condition: Patient Survey [LWYLTC]

Living With Your Long Term Condition

Firstly, thinking about today’s consultation:

1. As a result of your consultation today, do you feel you are…

(please tick one box in each row)

Much better / Better / Same or less / Not applicable
a / Able to cope with life…………………… /  /  /  / 
b / Able to understand your condition(s)… /  /  /  / 
c / Able to cope with your condition(s)….. /  /  /  / 
d / Able to keep yourself healthy…………. /  /  /  / 
Much more / More / Same or less / Not applicable
e / Confident about your health………….. /  /  /  / 
f / Able to help yourself…………………... /  /  /  / 

1. How well do you know the person you saw today?

(please place a circle round one of the numbers below)

(don’t know them at all) 12345(know them very well)

Clinician to complete / Clinician Name/ID:
Date: / Start time: / Finish time:

1. Please rate the following statements about today’s consultation

Please tick one box for each statement and answer every statement

How was the person you saw at…. / Poor / Fair / Good / Very Good / Excellent / Does Not Apply
a / Making you feel at ease……
(being friendly and warm towards you,
treating you with respect; not cold or abrupt) /  /  /  /  /  / 
b / Letting you tell your “story”……
(giving you time to fully describe your illness in your own words; not interrupting or diverting you) /  /  /  /  /  / 
c / Really listening ……
(paying close attention to what you were saying; not looking at the notes or computer as you were talking) /  /  /  /  /  / 
d / Being interested in you as a whole person …
(asking/knowing relevant details about your life, your situation; not treating you as “just a number”) /  /  /  /  /  / 
e / Fully understanding your concerns……
(communicating that he/she hadaccurately understood your concerns; not overlooking or dismissing anything) /  /  /  /  /  / 
f / Showing care and compassion….
(seeming genuinely concerned, connecting with you on a human level; not being indifferent or “detached”) /  /  /  /  /  / 
g / Being Positive……
(having a positive approach and a positive attitude;being honest but not negative about your problems) /  /  /  /  /  / 
h / Explaining things clearly……..
(fully answering your questions, explaining clearly, giving you adequate information; not being vague) /  /  /  /  /  / 
i / Helping you to take control……
(exploring with you what you can do to improve your health yourself; encouraging rather than “lecturing” you) /  /  /  /  /  / 
j / Making a plan of action with you …
(discussing the options, involving you in decisions as much as you want to be involved; not ignoring your views) /  /  /  /  /  / 

1. Now, please think about the last 12 months, when you received care and support for your condition(s)…

Please tick one box for each statement and answer every statement:

g.Did you discuss what was most important for you in managing your own health?

Not at all /  / Rarely /  / Some of
the time /  / Almost always / 

h.Were you involved as much as you wanted to be in decisions about your care or treatment?

Not at all /  / To some extent /  / More often than not /  / Almost always / 

i.How would you describe the amount of information you received to help you to manage your health?

I didn’t receive any information /  / I rarely received enough information /  / I sometimes received enough information /  / I always received the right amount of information / 

j.Have you had enough support from your health and social care team to help you to manage your health?

I have had no support /  / I have not had enough support /  / I have sometimes felt supported /  / I have always felt supported / 

k.Do you think the support and care you receive is joined-up and working for you?

Never /  / Rarely /  / Sometimes /  / Always / 

l.How confident are you that you can manage your own health?

Not at all
confident /  / Not very confident /  / Somewhat confident /  / Very confident / 

m.When you think about your healthcare in general, how often did you receive the healthcare you wanted when you wanted it?

Never /  / Rarely /  / Sometimes /  / Always / 

1. In general, would you say your health is excellent, very good, good, fair, or poor?

Excellent /  / Very
Good /  / Good /  / Fair /  / Poor / 

1. By placing a tick in one box in each group below, please indicate which statement best describes yourown health state today.

Do not tick more than one box in each group

Mobility / I have no problems in walking about / 
I have some problems in walking about / 
I am confined to bed / 
Self-Care / I have no problems with self-care / 
I have some problems washing or dressing myself / 
I am unable to wash or dress myself / 
Usual Activities
(e.g. work, study, housework, family or leisure activities) / I have no problems with performing my usual activities / 
I have some problems with performing my usual activities / 
I am unable to perform my usual activities / 
Pain/Discomfort / I have no pain or discomfort / 
I have moderate pain or discomfort / 
I have extreme pain or discomfort / 
Anxiety/Depression / I am not anxious or depressed / 
I am moderately anxious or depressed / 
I am extremely anxious or depressed / 

Finally, some questions about you:

7. Are you? / 10. Do you have any of the following conditions?
Please tick all that apply
Male / 
Female /  / Diabetes / 
8. How old are you? / Heart disease/angina/heart failure / 
35 or younger /  / High blood pressure / 
36-50 /  / Previous stroke / 
51-65 /  / Asthma/ Chronic lung disease / 
66-80 /  / Arthritis / 
Over 80 /  / Bowel problems (eg. Colitis, Coeliac, Chron’s) / 
9. What is your ethnic group? / Chronic kidney disease / 
White /  / Depression/Anxiety/other mental health problem / 
Mixed /  / Dementia/ Epilepsy/other neurological / 
Asian or British Asian /  / Other (Please specify)
Black or British Black / 
Chinese or other / 

Thank you very much for completing this questionnaire. Please hand it into reception.