Advanced Care planning

1. Dr Rachel Hames
Dr Ian Kelso
Blessings Ncube
Stephen Connolly

2. Agenda
 Introductions
 What is advanced care planning?
 New initiatives
 My care my way
 Message in a bottle
 Challenges

3. Our team
 Mutli-disciplinary team
 GPs
 Case managers
 Health and social care assistant (HSCA)
 Based at North Kensington Medical Centre
 5000 patients
 627 patients aged 65 and older

4. Advanced care planning
 ‘Thinking ahead’
 Anticipatory treatment plans
 Patient wishes on future care
 Create a seemless transition between primary and
secondary care
 Share treatment plans between groups of health and
social care professionals
 Prevent unnecessary hospital admissions

6. My Care My Way• Enhanced Care for People over 65
 West London is a national ‘Pioneer’ for Whole Systems for
patients aged 65 and over.
 Integrated Care Service
 GPs will be at the centre of organising and coordinating
people’s care.
 A multidisciplinary approach involves drawing
appropriately from multiple disciplines to explore
problems outside of normal boundaries and reach
solutions based on a new understanding of complex
situations

7. What does this mean?
• There are teams aligned to GP practices to support care delivery
• Key staff members are Case Managers and Health and Social Care Assistants
Case Managers
• Work with the most complex
patients
• Support patients to develop detailed
care plans – closely understand
patients’ health and social care
needs
• Act as first point of contact
• Co-ordinate onwards referrals to
other services
• Stay involved in co-ordinating care if
patient needs to go to hospital or
access urgent care services
• Work closely with the GP to co-
ordinate care
• Support patients to develop self care
plans and access self care services
Health and Social Care Assistants
• Work with the less complex
patients
• Support patients to develop care
plans
• Act as first point of contact
• Refer on to other services as required
• Co-ordinate the delivery of self care
• Support the GP and Case Manager
• Identify patients who may benefit
from being in a higher tier
• Keep patient records up to date
Each hub will also have a team, including: receptionist, administrator, analyst,
pharmacist social worker and geriatrician input

8. Patient story: What it means to be
a health and social care assistant
 John is 74 year old patient who lives with his wife in a 3
bedroom house in North Kensington. His wife has
multiple complex health problems including advance
stage dementia. His life is being her full time career.
He neglects his own health needs as all his time is
spent attending to Joan.

9. Strong family Support
 John and Joan have support from a daughter whom
lives locally. She has a young family of her own so help
is limited but she helps out when she can. Joan has a
full package of care 4 visits per day with regular visits
from the District Nurse.

10. Me and My Care My Way
 When John was referred to My Care My Way by his Doctor
he was classified as a Tier 1 patient. During his first
assessment with the Health and Social Care assistant he
spoke of a typical day attending to Joan it was very clear
that he had no time for himself and was rapidly
approaching burn out. A PAM questionnaire was
completed with John highlighting his knowledge, skills and
confidence around his own health care needs. Together we
then completed a personalised care plan for John this gave
his the chance to be actively engaged and talk about his
own health care giving him space to open up and talk about
his feelings and concerns about his health and the future.

11. Follow Up
 John told me he felt really grateful for this new service
and how uplifting to know that there is a whole team
of health, social care and voluntary services who will
be able to support him if his health needs change in
the future. He spoke highly of the massage treatment
and how he had noted a significant reduction on his
stress levels, being able to switch off and how he felt
generally more relaxed with a greater sense of
wellbeing after each session.

12. • Breaking down barriers
between all organisations
• Holistic and proactive
continuity of care
• Personalised and tailored to
all the patient’s needs
• Clear accountability
• Shared values
• Supported by integrated
care centres as centres of
service
• Co-ordinated across
organisations breaking
down barriers
Principles

13. My care my way hub

14. Message in a bottle
 A key component in Anticipatory Care Planning and
Crisis Management
 Devised with Patient and Medical Team
 Is Kept in the Patient’s Fridge
 Has Key Medical Information re: patient’s Medical
conditions, medication and self management
strategies – as well as Key professionals and NOK
involved in Patient Care
 Aids CIS/LAS to support with relevant interventions
this avoiding unnecessary hospital admissions

15. Challenges
 Input from whole of MDT
 Ensuring care plans are actually followed
 Care plans in primary care are accumulated over time
 Discussing end of life care in a community setting

16. Any Questions?