Transcript Consensus Event 24th November - Model testing via Personasx

Model of Care – Consensus Event feedback
TESTING THE MODEL ON THE PERSONAS
On November 11th, the Stockport Together Programmes held a Consensus Event to share progress and gain consensus with the developing Models of
Care. Seven ‘personas’ were used to test the proposed model – to see whether the person’s needs would or would not be met, and highlight
perceived issues, risks and gaps. The following Personas were used:
• Chronic condition but self-managed (Gerald & Jerry)
• Limited Reserves and Exacerbations (Alice & Ellen)
• Frail (Nora)
• Healthy (Bob and Jane)
There was general consensus that the model of care would address the needs of each of the personas, although there needed to be further
development / articulation of the interfaces between the programmes and increased sensitivity.
Social care, mental health and third sector elements were not felt to be articulated strongly enough, and the model of care could put more emphasis
on the huge change in workforce culture and public expectation / behaviour that will be required.
The following slides capture the notes made during discussions for each persona in more detail.
CROSS-CUTTING COMMENTS and GAPS
Where dos the ambulance service fit into the model?
What is the out of hours model?
Potential to strengthen ambition in relation to prevention and lifestyle offering
How can we pick up people (not previously known to the system) before they
exacerbate?
• Model should look beyond health and social care to other public / private sector partners
eg housing, fire, police to ensure it’s fully holistic (and sustainable) model
• How do we recognise that people are an asset as well as users of resource ie community
asset building? The model is currently very practitioner and service focussed.
• Is it sustainable to be so proactive? eg ‘Frail’ persona is currently alimited cost to the
system
•
•
•
•
• Want assurance that the IT systems will be able to talk to each other at the
right level.
• How can we use data more to enhance professional decisions?
• Virtual Access for planned care appointments / accessing consultants for
advice and guidance – will require cultural shift – this will take time which
needs to be reflected in implementation timescales.
• End of life care needs a wide remit to include people who may die within 5
years – need to include advance directives which underpin care planning so
people have their wishes respected rather than working on a clinically safe
model.
• Will there be sufficient capacity released to support community-based care?
NEXT STEPS
• The programme teams have reflected on all the comments raised and will continue to address the issues and gaps as the models are designed in
more detail throughout December and January.
• It was agreed that it would be useful to test the model of care on other personas, with more specific needs. As a result, the programme will
1 Care Home residents; additionally the persona for ‘Chronic condition,
develop additional personas around Dementia, Mental Health, End of Life,
stable but with serious disability’ will be added to the cohort to be used going forward.
- Chronic condition but self-managed








52 years old
Type 2 Diabetes
Lives with his wife in the large family home
Son and daughter have moved away
Would like to exercise more but has no time
Beginning to feel stressed as he is the main carer
for his wife who suffers from dementia
Not eating well
Lost touch with friends
Main touchpoints:
 GP
 Pharmacy
 Local shops
 Local club
 TV/radio
 Petrol pumps (adverts)
 Bus stop/train station
 Diabetes clinic
Model of Care – Consensus Event
Other touchpoints:
 Carers group
 Alzheimer's society
 Meadows (mental health)
 Work place
To Improve:
 GPs and Meadows to get the
offer right
 Develop a dementia friendly
society
 Targeted social media
 Take health checks to the
person e.g. workplace
 Target sports clubs/gyms for
‘unfit’ people
 Support children to
reinforce key wellbeing
messages to parents
TESTING THE MODEL OF CARE FOR GERALD
AIMS
• Manage diabetes appts.
• Address lifestyle issues
• Develop future plan for
dementia care
• Reduce social isolation
• Maintain financial
security
OUTCOMES
• Reducing
hospitalisation
• Increasing quality of
life
• Increase coping skills
ISSUES / RISKS
• Will the new model be sensitive enough to pick up conditions early
enough?
• Will the new model know Gerald’s touchpoints?
• For Gerald and his wife’s dementia – need to look at how the system will
manage two complex patients. Gerald’s duties as the main carer for his
wife may impact on his ability to self manage his condition. This will
require the system and health & social care professionals to take an
holistic view of the their needs and consider them as a unit.
ACTIONS IN THE MODEL
• Advice on diabetes and lifestyle support service (Prevention &
Empowerment)
• Primary Care follow up i.e. missed appointment (Proactive)
• Practice Nurse intervention
• Targeted intervention team to relieve carers’ duties
• Neighbourhood support (Proactive Care)
• Access to mental health support (Proactive Care Neighbourhood Model)
• Access to Healthy Minds
• Access to Social Care support services
• Support family engagement
GAPS
• Needs more detailed thinking about points of access back into the system following
an exacerbation & how the system will identify deterioration in patient condition
• Further clarity about how social care and mental health services will be accessed.
• Further clarity / understanding of the new neighbourhood model and the services it
will deliver.
• Need to develop further how the neighbourhood model will provide increased
community support.
• Important that any ‘soft’ intelligence is reported back into Primary Care in order to
better support the person.
• Need to look at how the system will break down barriers between health and social
care professionals – to be addressed through the workforce and IT enablers.
2
• Cross-border issues to be considered
Model of Care – Consensus Event
- Chronic condition but self-managed









69 years old
Has COPD
Lives with his wife who has bipolar
Annual COPD reviews at GP
Shortness of breath but walks everyday
Has support from his wife but struggles to attend
all appointments
Undertaken pulmonary rehab
Has inhalers and ‘rescue meds’
Suffered from depression when wife diagnosed
Main touchpoints:
 GP
 Pharmacy
 Carers group
 COPD community nursing
team
 Outpatients
 Age UK
 Routine annual COPD review
To Improve:
 Share information
between GPs
TESTING THE MODEL OF CARE FOR JERRY
AIMS
• Asking Jerry what matters
to him!
• Optimising his health and
wellbeing.
• Supporting him as a carer.
• Improving his quality of
life.
ACTIONS IN THE MODEL
OUTCOMES
• Managing any exacerbation
in the most appropriate
setting.
• Fewer interventions.
• Empowering Jerry to
manage his LTCs.
• Improved quality of life.
• Adherence to Care Plan.
Accessible care plan.
‘Birthday Checks’
Educating him/them as carers.
Socialisation, ask him/her.
He can get help quickly for his wife.
Delivering education via interactions (e.g.
pharmacy, telephone).
• Co-ordinated care plans.
•
•
•
•
•
•
3
IN CRISIS
• COPD
• Depression
• Wife passes away
Actions 15 YEARS AGO
• Behaviour change –
smoking cessation
(measuring lung age)
• Identification and
targeting
• Assessing and engaging
Model of Care – Consensus Event
Limited reserve and exacerbations







71 years old
Lives alone, divorced, no family
Heart problems difficult to diagnose, chest pain,
COPD controlled by medication
Visits GP weekly
Anxious
Calls OOH GP frequently due to chest pain, always
resulting in admission
Main touchpoints:
 GP
 OOH GP
 ED
Other possible touchpoints:
 COPD service
 Pharmacy
 Third Sector ( Age UK, Sheltered homes)
 TPA (if referred)
 Psychotherapy
 Healthy minds
TESTING THE MODEL OF CARE FOR ALICE
AIMS
OUTCOMES
• More socially active / reduce loneliness.
• Living independently – self-caring.
• Improved mental and physical health and
wellbeing (meaning to life will be individual
to her).
• Stop smoking.
• Self-motivated and does not want to access
the system.
• Less anxious - educated about own condition
- what to expect / how to manage.
• Ability to say ‘someone’ will see you in the
morning.
• Only a jointly developed care plan will meet
her needs – not just GP
• Reduced reliance on
the system
• Fewer GP
appointments / OoH
calls / ED
attendances
• Reduced
dependency to avoid
hospital admissions
• Problem-orientated
medical records.
ACTIONS IN THE MODEL
• Complete a holistic needs assessment (mental, physical and
social needs)
• Care Plan tailored to individual needs and goals
• Identify keyworker who initiates regular contact and
engagement – consider how this will work 24/7.
• ‘Referral’ (signposting) to organisation and services to meet
her needs (for all needs) e.g. through TPA , Age Concern
might make contact and help form social group.
• Borough wide services/specialists to input into the care plan
if required for ongoing health needs.
• ‘Pets For People’ – physical exercise, meaning to life
• Arrange for proactive conversation – avoid repeat admission
• ‘problem patient’ for GP – will have community-based
alternative to the acute system
ISSUES / RISKS
GAPS / COMMENTS
• Due to her social isolation, would Alice only be picked up at
point of exacerbation?
• IG and consent – dependent on information sharing. Could how
maternity work help overcome IG issues? (patients hold their
own records and are in control of sharing)
• How do we ensure that important information is not buried?
• How do we ensure that the care plan is based on individuals’
needs when they might not know what they need or want?
Need motivational interviewing skills - not only medical focus
• Basic need for a lifestyle is not being met.
• Her needs are unlikely to be ‘health’ related. Likely her
mental health is driving the physical health issues. Likely that
a high number of attendances would not have taken place if
Alice was not socially isolated and anxious.
• Challenge to pay people based on outcomes – difficult to
measure. People can be grateful even when not treated well.
rd
• How far are 3 sector services embedded into Neighbourhood
teams?
• Gaps around impact of mental health and social isolation.
• How does the integrated model work 24/7? 8pm is too early to end eg 7%
access up until 11pm & anxiety or isolation are prevalent in the evening.
• Happiness assessment/check built into the model/assessment.
• Link between ED knowledge and INS e.g. judgement over those that they think
will come back in again.
• Link between access and discharge team between Urgent and Proactive – but
also the team looking after them whilst in the system.
• Concerns over losing records but not vastly realised.
• Put rescue medications in plan.
• Care plan is ‘golden thread’ to tie up all aspects of her care – must ensure it is
a live document for all to read and input inc available to NWAS and ED.
• Needs to include where she lives and understand housing assessment
• Requires an easy system to connect those willing to volunteer and the need.
• Social activities, Age Concern, group activities.
• Strong emphasis on the solution to ensure Alice has a purpose and meaning to
life / reason to want to get4better as the system may be where she gets her
social interactions and security from. Don’t just focus on medical care plan.
• What are the urgent pathways (eg NWAS pathfinder) as alternatives to ED?
IN CRISIS
• Do we have the tools in place to get her
back to ‘normal life’?
• Does the person want to get back to
‘normal life’?
• Differentiate between the elements
that are ‘transitional’ and what is being
put in place permanently.
• Being able to access a ‘known’ person.
• Method to pull her back out rapidly.
• Specialists can be assessed ‘rapidly’.
Actions 15 YEARS AGO
• If this had been a critical turning
point in her life, she would have
been offered greater support e.g.
bereavement or counselling
• Greater physical activities
• Tapped into and utilised her skills
and interest
• Stopped smoking
• Healthy living advice
• Public health and prevention would
be in place outside of the health
system
• Public health would have proactively
found and targeted her
• Work-place health checks e.g. blood
pressure, smoking and alcohol status,
blood sugar, lipids – getting those
who are aware and in denial to
access services
• Happy check as part of a health
check much earlier on
• Parity over mental and physical
health – no stigma around mental
health
Limited reserve and exacerbations










85 years old
Lives in a 2 storey house
Husband died 3 months ago
Had a heart attack 2 years ago which she takes
regular meds for
Visits her GP for health checks
Is mobile and does her own shopping
Limited circle of friends
Feeling lonely since the death of her husband
Had a fall at the weekend and fractured her
shoulder
Stayed in hospital for a few weeks and developed an
infection
Model of Care – Consensus Event
Main touchpoints:
 GP
 Friends
 Cleaning agency
 Bereavement services – husband
may have previously managed
finances – more burden
 Access to community engagement
activities is probably low
 Some support networks
To improve:
GP service – if they flag the bereavement then do something, outreach
to relatives, link up with existing service from GP – set up service –
chat on telephone; someone from GP practice to get in touch with
her, but not just looking at bereavement, look at her holistic needs
Age UK – very useful resource re prevention and bereavement
Calls from Macmillan nurses for cancer related death
Husband’s death, change of routine, anxiety ; social work review re
resilience, bereavement; the hospital only give a leaflet re
bereavement
Example – husband used to change lightbulb – death of husband – dark
home – serious fall so lack of support at bereavement stage could have
huge impact on here long term health and support needs.
TESTING THE MODEL OF CARE FOR ELLEN
OUTCOMES
AIMS
Keep her at home and out of hospital.
Increase social contact.
Decrease risk of falls.
Provide recovery support for personal
needs.
• Support Ellen with bereavement.
•
•
•
•
• More resilient and
independent
• Better supported
ACTIONS IN THE MODEL
• Designated GP.
• Review into why Ellen has fallen.
• GP to refer to Zone 3 Planned Care – most
appropriate offering to aid recovery of
shoulder.
• Neighbourhood Teams to refer to Age UK (Age
UK involved in MDT?).
• Build relationship with Care Coordinator.
• Neighbourhood team to refer to relevant
bereavement service.
GAPS
COMMENTS
• If it wasn’t for recent fall, how would Ellen be on any team’s radar?
Combined social elements (recent bereavement, associated issues of
having to cope on her own etc) and potential exacerbation for her
heart condition would not be picked up in the new system.
• Unclear where / how Ellen is referred to the teams – would she be
referred back to her GP (following discharge into Zone 3 outpatients
for her fall) or to the Neighbourhood team? Further clarity on
referral route needed here.
• Current prevention agenda is focussed on a much younger cohort. 15
years ago Ellen would have been 70. Increasing her social resilience
(attendance at tea dances, community tai chi classes etc) was felt to
be the key prevention area for her that provides the most help and
support to her current situation – these needs would not be
addressed as the current prevention agenda is geared around
prevention of health conditions, rather than social ones.
• Overall agreement that the new system would meet most,
if not all, of Ellen’s needs quite well. The use of
neighbourhood teams to help oversee and coordinate the
many elements of her care plan (including bereavement
management, managing her social isolation and her
physical recovery from her fall) was felt to be a
significant improvement to the current situation.
• New system, especially around crisis point – once in A&E
for her fracture, the new system would allow the A&E
consultant to be assured of her care in the community,
thanks to the integrated electronic record notifying him
of her other conditions, and discharge her back to her
neighbourhood team
5 rather than admit to the hospital.
IN CRISIS
• If presented to A&E, discharge to
Neighbourhood Team (no admission to A&E).
• New World I.T. – integrated record system
will flag up messages to Neighbourhood
Team whilst in A&E.
• A&E Consultant will be able to see her Care
Plan - gives assurance to discharge Ellen
Actions 15 YEARS AGO
• Commission preventative exercises e.g. Tai
Chi
• Prevention to hit 70 year olds – targeted
message to all (tea dances etc.)
Model of Care – Consensus Event
- Frail









98 years old
Lives alone in her own house
Has mild hypertension which is monitored by the GP
She does her own cooking and cleaning
Is becoming unsteady on her feet but has not fallen
Losing confidence as a result of near misses
Wants to stay at home as long as possible
Daughter lives nearby and visits regularly
Daughter helps with shopping
Main touchpoints:
 GP
 Daughter
 Friends and neighbours
 Hospital outpatients
 Local shops
TESTING THE MODEL OF CARE FOR NORA
OUTCOMES
AIMS
• Maintain her quality of life and
independence.
• Support her living in own home as
long as possible
• Understand her choices
• Empower her to make own
choices and understand her
choices for end of life.
• Reduce the risk of her falling.
• Plan in place if anything happens
to daughter.
• Cope well with illness at end of
life.
• Wants to have finance in order.
• Minimise her risk factors and
minimise her loss of control (e.g.
by admission to hospital).
ACTIONS IN THE MODEL
• Reduce isolation.
• Proactive approach to her situation – make
her aware of availability of services and ask
what she wants to offer.
• Acknowledge she is an asset.
• Plan for working with family and/or carers.
• Reduce opportunity to fall / risk of falling
and injury in home. Maintain mobility
• Reduction in number of ‘hand-offs’ to lessen
risk of ‘slipping through net’.
• Care plan sets out formal process for support
in lieu of daughter if/when needed.
• One care plan for health, social, mental
care.
• Have best E.O.L. experience possible.
• Has all legals in place to ensure finance is
not an issue moving forwards.
• Plan for if/when a crisis occurs.
ISSUES
• Is the Model able to identify Nora early enough?
• Who is the ‘navigator’ through the system if
medical needs are low? Can it adapt to the
‘right’ person for Nora?
• Does the system model assume all practitioners
are the same/have the same skills?
• Persona not recognising how individuals can be
an asset as well as users of resources – eg Nora
15 years ago
• Don’t categorise all ‘frail’ people the same –
don’t assume everyone who lives alone wants
or needs more contact with services /
community.
• Need to ensure care co-ordinator role is
contactable 24/7 so people don’t lose
confidence if not available
• Assessment of needs following alert via risk stratification.
Find and treat.
• Generic worker or volunteer to undertake assessment
including mental/emotional wellbeing and cognitive
function. Understand if she is happy living as she is now –
what are alternatives? Time to consider options.
• Key link worker to co-ordinate her needs. Keep revisiting.
• Give information. Education and Confidence
• Fall assessment done to risk assess staying at home.
• Assessment for hypertension and appropriate treatment.
• Reduce anxiety around environment.
• Build a team around Nora before she reaches crisis.
• Full and detailed alternative to current care in care plan.
• Ability to escalate services quickly when required.
• Someone to have a real and honest conversation about
E.O.L. pathway.
• Help and support given to Nora so she feels happy with
financial outcomes.
RISKS
• Increased dependency on system rather than family/community.
• Cost: potentially 16,000 ‘Nora’s in Stockport – currently she has a
limited financial burden – to be sustainable, need to ensure inputs to
frail elderly don’t outweigh the benefits
• New models dependent on paid carers – requires strategy to increase
morale and motivation of this workforce.
• Nursing/residential homes are outside of the governance of current
partners – how can we engage more in MoC?
• Workforce risks (age demographics / culture)
• Training and expectations of new recruits into system. Education
provision is insufficient.
• Lose personalised care / person known to individual, e.g. small GP
practices & 24/7 care. New model of neighbourhood wide working /
6 relationships between
different specialist advice could erode strong
individuals / practitioners - more people escalated in the system.
• Too much energy on people whose behaviours we can’t change
IN CRISIS
• Minor fall overnight – medically
does not need hospital but
needs support overnight – is this
available?
Actions 15 YEARS AGO
Training to look after self
Electronic/digital literacy
Assessment of environment
Prevention of falls for 80+
How is she part of the
community? Broaden social
network
• What her aspirations are – can
she volunteer/participate? looking after grandchildren
• TPA/WIN involvement
• Find out what she is doing to
keep active and healthy – set
things in place to keep this
going as long as possible
•
•
•
•
•
GAPS
• Lack of clarity around Prevention and Proactive Care interface
for Nora – who makes first contact and how?
• Non medical or minor medical issues not supported – eg
overnight support at short notice for her without hospitalisation
• Hospital EPR vs. Stockport Health Record. Not assured that
these will speak effectively to each other.
• Not sure have the capability/capacity to turn patients around
quickly and get her home if admitted for minor medical issues.
• Where does the ambulance service fit into model?
• Lack of clarity around community asset building – model is very
practitioner and service focused.
• Response to crisis – model needs to clearly articulate options to
keep people in their residence rather than hospital if that is a
choice a person makes (what about head injury after a fall)?
• How well engaged are NWAS?
Model of Care – Consensus Event
- Healthy






Touchpoints:
48 years old
Lives alone
Rents a flat above a shop
Smoker
Drinker
Taxi driver








Employer
Work bases/license renewal
Radio listening
Pharmacy
GP
Pub
Supermarket
Off license
TESTING THE MODEL OF CARE FOR BOB
AIMS
ACTIONS IN THE MODEL
OUTCOMES
Bob’s Aims:
• Stay healthy and working.
• Wants easy access to H&SC if
needed.
• Wants meaningful relationships
and good network (e.g. pub with
mates).
• Finances and housing – meeting
his needs to stay independent.
Our Aims:
• Maintain his current level of
health
• Easy access equals less stress for
patient and healthcare provider.
• We see those who really need it.
• Encourage Bob to see GP if he
gets a cough.
• Reduction in risk
factors.
• Bob becomes
interested in his
health and wellbeing.
• Doesn’t develop
severe condition and
end up in hospital.
• Bob becomes more
active (social and
health benefits).
Getting to Bob:
• Radio campaigns (social marketing)
• Public space marketing e.g. buses and
billboards
• Social marketing e.g. web banners,
Twitter/Facebook advertising
• Use app to take blood pressure regularly
• Online booking of appointments
• Health and care finder app for trusted advice
• Workforce are trained to talk to Bob e.g.
Neighbourhood Hub goes to library,
receptionist goes to GP, receptionist
• New Estates approach, new workforce.
Finding Bob:
• Workplace engagement (taxi meetings)
• Taxi driver medical (annually with GP, look at
whole person)
ISSUES & RISKS
GAPS
• Prevention in every
pathway needs
more development
e.g. Urgent Care
interface.
• Ensure H&C finder
app has broader
range of exercises.
Risk:
• Active lifestyle
‘services’ – will it
get to people?
• Is too much going
through the GP?
• Concern that GP capacity won’t be released – so prevention advice needs to be
undertaken by someone else.
• Create capacity for people e.g. admin to be trained in health chats.
• Could strengthen ambition of the model in relation to informatics (apps / virtual
health trainer based on data entry), also active lifestyle offering (eg more visibility
of various local groups), and targeted marketing (website banner advertising)
• Low investment into active lifestyles.
• Mental wellbeing needs parity and explicit focus in the model.
• Need to be all inclusive e.g. L&D and mental health problems.
• Early alcohol intervention – how to access Bob.
• Promotion of online booking – no appointment to have one!
• Focus on active lifestyle with community development. Targeted marketing with
health messages.
7
• Working with Stockport Homes - healthy people.
• Investing in Stockport – work with P&E experts regarding wellbeing and wider
determinants, regeneration etc
• Pharmacy – goes in for Rennies, gets leaflet on
smoking, offered flu jab on basis of work
(Healthy Living Pharmacy is trained to discuss)
• Supermarket stall giving health checks &
advice
• Community Health Champions e.g. friend has
a chat.
• Locally-based health trainer calls him/sees
him to discuss checks, healthy lifestyle and
5yr health checks
• Healthy Chat people know local based places
for activity (physical) and are trained in
motivational techniques including mental
health advice.
• Goes to see GP, then is offered to see a
health trainer after who provides that advice.
IN CRISIS
• Suicide attempt
• Chest infection
– needs access
to GP
Actions 15
YEARS AGO
• Active:
encourage
fitness legacy
e.g. football
clubs. Will
affect smoking
and blood
pressure
COMMENTS
• Other potential ‘Quick Wins’ identified:
- Opportunity for Bob – care service/ MOT garage health trainer there or
leaflets etc.
- Taxi drivers licensed by SMBC – could discount be offered as reward for health
initiative? Eg low BMI, Health Trainer course
- Train taxi drivers as health trainers as they talk to a lot of people
- Use taxi driver e.g. sat nav system to promote health messages
- Health & Care finder app to include community classes / groups (eg meetups,
dancing, arm chair aerobics) eg Mums in the Know model
• Need social, local, active to get people to go toeasy range of activities.
• Engage with parents at kids’ football/other sports club – FAMILY FOCUS.
• Focus on dentist e.g. identify people, signposting e.g. smoking. GP/others
encourage dental visit.
• Ambition; use of H&C personal record linked with Emis e.g. GP says breathless
leads to texts/app message regarding smoking.
Model of Care – Consensus Event
- Healthy








60 years old
Retired and married
Husband has heart disease
Looks after grandchildren 2 days a week
Elderly mother with dementia who is in care
Jane gets flue jab and BP checks
Books appointments online
Becoming worried by Google searches so relies on GP
for advice
Main touchpoints:
 GP
 Pharmacy
 Internet
 Family
 School/ nursey gate/ playground
 Residential home – as a carer
TESTING THE MODEL OF CARE FOR JANE
AIMS
• Keep her healthy and well
• Empower her to continue to
support her family.
• Identify risks early and
prevent exacerbation (of her
health and of her family
situation).
ACTIONS IN THE MODEL
OUTCOMES
•
•
•
•
•
•
•
•
Stays healthy
Doesn’t require intervention (£)
Stays healthy for longer
Positive impact on her
family/community
Better outcomes for her dependents
Supports wider system
She feels better informed and less
worried/stressed
Prevents exacerbation.
Regular health screening e.g. blood pressure, cancer.
Physical Activity Services
Healthy Living Pharmacies
‘trusted advisor to worried well’
Husband’s LTC monitored/cared for at home/in community
Clear signposting to reliable health information (for her and
her husband)
• Apps/emails to her with advice/Stockport website,
masterclasses on specific issues.
• Online self-assessment (and advice)
•
•
•
•
•
•
ISSUES
RISKS
GAPS / COMMENTS
• What community links and social connections
can support Jane to stay healthy and
empowered to look after her family?
• How can the model be personalised to Jane as
an individual?
• How capture the husband’s needs
electronically / consider them as a family unit
rather than individuals?
• Proactive Care Model may put more strain on
people like Jane – healthy people caring for
others – how do we recognise people’s
assets?
• 7 day working – unlikely to see the same GP
every time which is harder to assess wider
needs if they don’t know you.
• Will Jane have the time to engage?
• Is there sufficient capacity in the community, especially DNs – will this
be in place before the outpatient shift? Otherwise will be moving
bottlenecks around the system.
• Will there be more care commissioned at home?
• Public mindset/expectation/behaviours – e.g. A&E, GP, triage, how do
we educate or change this?
• Is there enough for the average healthy person? Not clear if sufficient
to reduce her concerns and reliance on GP as ‘worried well’
• Need to test model on a person in a care home.
• Making use of touchpoints – how do healthy people get considered
holistically? Who is asking Jane how she is doing?
• Does Jane have enough information on her husband’s heart disease?
(masterclasses as well as website info)
8