Jaswal, Sabrena K.

Mikelyte, Rasa

Kent Academic Repository

Kent Academic RepositoryFull text document (pdf)Copyright & reuseContent in the Kent Academic Repository is made available for research purposes. Unless otherwise stated allcontent is protected by copyright and in the absence of an open licence (eg Creative Commons), permissions for further reuse of content should be sought from the publisher, author or other copyright holder. Versions of researchThe version in the Kent Academic Repository may differ from the final published version. Users are advised to check http://kar.kent.ac.uk for the status of the paper. Users should always cite the published version of record.EnquiriesFor any further enquiries regarding the licence status of this document, please contact: researchsupport@kent.ac.ukIf you believe this document infringes copyright then please contact the KAR admin team with the take-down information provided at http://kar.kent.ac.uk/contact.htmlCitation for published versionJaswal, Sabrena K. and Mikelyte, Rasa  (2018) Encompass Vanguard: Evaluating Staff & ManagerPerceptions.    In: Local Care MDT Conference, 18 April 2018, Maidstone, UK.     (Unpublished)DOILink to record in KARhttps://kar.kent.ac.uk/70488/Document VersionPresentationSabrena Jaswal & Dr. Rasa Mikelyte University of KentApril, 2018Encompass Vanguard: Evaluating Staff & Manager PerceptionsBackgroundResearch & Evaluation TeamX Professor Jenny Billings and her team from the Centre for  Health Services Studies (CHSS) at the University of KentProf. Jenny BillingsDr. Melanie Rees-Roberts Sabrena JaswalDr. Rasa MikelyteCentre for Health Services Studies www.kent.ac.uk/chss Community Hub Operating Centres in Kent (CHOCs)X The objective of the CHOC is to support system sustainability through the creation of a holistic community based model of integrated service delivery. They commenced in 2016 and have now been rolled out in Canterbury, Faversham, Whitstable, Ash and Sandwich. They represent a fully integrated health and social care team; offering primary, community and social care services.X Aims of the CHOC:X To improve user experience of co-ordinated care and self-management at homeX To contribute to a reduction in A&E demand and onward admission in the short termX To reduce pressure on acute services and long term care home placements in the longer termCHOC LocalitiesFaversham CHOC2 practices -30,743Whitstable CHOC2 practices ² 38,574Canterbury S. CHOC3 practices ² 46,632Canterbury N. CHOC4 practices ² 47,391Sandwich & Ash CHOC3 practices ²17,444The EvaluationLocal Evaluation Research QuestionsI. What impact are the CHOCs having on user outcomes and experience? II. What are the components of the care model delivery (or ¶DFWLYHVXFFHVVIXOLQJUHGLHQWV·WKDWDUHUHDOO\PDNLQJDdifference? III. What are the influencing contextual factors and how have they affected implementation and outcomes? IV. What changes to the use of resources and activity in the local health system have taken place and to what costs? V. What could be improved, replicated and sustained?Data CollectionPatient InterviewsPatient SurveyStaff InterviewsStaff QuestionnaireMDT ObservationsData Collection: Staff & ManagersPatient InterviewsPatient SurveyStaff InterviewsStaff QuestionnaireMDT ObservationsInterprofessional Collaboration Scale$&ORVHU/RRN«X The scale looks at: X Experiences of working relationshipsX Reported perceptions X TeamworkX ThemesX CommunicationX AccommodationX IsolationQuestion ThemesI feel that patient treatment and care are not adequately discussed between and among team membersCTeam members cooperate with the way care is organized AIndividuals are not usually asked for their opinions I11 Kenaszchuk C, Reeves S, Nicholas D, Zwarenstein M. Validity and reliability of a multiple-group measurement scale for interrprofessional collaboration. BMC Health Services Research, 2010; 10.Collaboration and the CHOCs2.732.93.23.83.91234Communication Accommodation Isolation1 =  Strongly Disagree,   2 =  Disagree,  3 = Agree,  4 = Strongly AgreeInterprofessional Collaboration ScalePilot (N=24) Full Implementation (N=22)Staff & Manager InterviewsStaff/Manager Interviews to DateStaff roleTarget RecruitmentNumberInterviewsCompletedManagers268CHOC GPs 2Nurses 1Other Allied HealthProfessionals8Other roles within CHOC1Other roles outside CHOC2Total 22Experience with the Implementation of the CHOCX You have a bit more confidence in your care plans EHFDXVH\RXNQRZLW·VKDGWKDW0'7DSSURDFKVR\RXknow all basis have been covered (SM1)X How you can be integrated and not be able to share WKDWLQIRUPDWLRQZDVFKDOOHQJLQJWREHJLQZLWK«LW·Vbetter and developing and  with the integration of EMIS DQGWKH0,*ZH·YHEHHQDEOHWRPRYHWKDWIRUZDUG(SM10)X 7KHUH·VDQHOHPHQWRIWUXVWWKDW´\HV\RXNQRZWKLVLVJRLQJWRJHWGRQHµEHFDXVHSHRSOHDUHFRPPLWWHGIRUthis to work (SM6)Coordination and Impact on Patients X I WKLQNZH·YHDYRLGHGTXLWHDIHZFULVHVIURPSDWLHQWV(SM11)X Medicines management were the hardest people to get referrals through WRDQGQRZWKH\·UHDWRXUPHHWLQJVLW·VIDQWDVWLF(SM2)X The voluntary sector has been hugely helpful in stepping in; the Red Zebra team are often picking up OLWWOHJDSVZKHUHVRFLDOVHUYLFHVFDQ·WUHDOO\KHOSRUhave been very slow too (SM13)X You have a face-to-face conversation around the table about this patient and you ² not always ² but you can get a solution or an action right then and there so \RX·UHQRWZDLWLQJ(SM3)Sustainability of the CHOCsX People needed to be afforded the time and the availability to be able to do it alongside their normal role (SM1)X Need access to the systems during the meetings [i.e. EMIS and CIS] (SM4)X Have a representative from each organisation [not everyone from health and social care organisations attend] (SM4)X We do not have a sustainable workforce with the skills required to continue (SM3)Professionals Working Across CHOCsX The relationships between the providers has gone from non-existent and full of animosity to respectful, open, honest, supportive (SM3)X ,W·VKHOSHGEH\RQGWKH&+2&LQXQGHUVWDQGLQJZKRLVout there, what other services are there, particularly the voluntary services (SM5)CHOC MDT ObservationsObservationsX The observations involvedX 3 CHOCs X 4 consecutive MDT meetingsX 2 observers X 12 CHOC MDT meetings observed in totalX Observers were non-participatory members at the meetingX Focussed Ethnographic ObservationsX Observations were handwritten and included sections for free text and sections which were more structuredX Aim: X To identify what elements of the process are leading to what outcomes for service usersX To better address our objective: What are the components of WKHFDUHPRGHOGHOLYHU\RU´DFWLYHLQJUHGLHQWVµWKDWDUHreally making a difference?INPUTSNational policy directives Mention of national policy directives or guidelines.Local Guidelines Mention of local guidelines/rules/regulations.Resource issuesMention of resource issues (e.g. staff, time, money). How do these factors affect decision making? Evidence of resources being pooled?Other servicesMention of other individuals/services/team within organisations that impact on options/decisions made.Context Other broader contextual factors influencing decision making.Presenters Who presents cases up for review? How? How are agenda items framed?Targeting of PatientsWho are they targeting? How? Any particular health conditions? Is there a formal approach (risk stratification)? Patient characteristics Patient characteristics ʹ any variation? Voluntary Sector Input What input does the Voluntary Sector Organisation representative give (if they attended)? Missing info Mention of missing information? How does this impact on decision making?PROCESSLeadership styleIs there a clear role or several competing leaders? Do they encourage involvement or limit contributions?Team dynamics Does everyone contribute to discussions/actions and decision making? How?Overall Purpose What appears to be the overall purpose of the MDT? Case Management & ReviewHow is the case management and patient review managed? What information is provided? Who provides the information? Who takes action?Performance Measures What measures are they using to measure performance of the MDT?Mediators Other mediators, processes influencing decision making.OUTPUTSOngoing & new cases How many cases are discussed in the meeting? Number of new cases/ongoing cases.Actions agreed on What actions are agreed? Are actions from previous meetings reviewed? Decision making & recording patternsWho records the decisions made? Is there a verbal summary and rationale? Is responsibility for implementation discussed? Any other outputs by the MDTOUTCOMES Outcomes/end resultPatient experience, service utilisation, clinical, patient-reported and wider outcomesCost Savings Evidence in the meeting of cost savings in terms of changes to staff input in patient careIdentifying problems Did they identify delays or doubling up of care, patient problems, other problems in care?Remedying problems Did they remedy delays or doubling up of care, patient problems, other problems in care?Analysing the ObservationsX The information recorded on the structured part of the schedules has been analysed thematically within the main categories of:X INPUTSX System & Organisation FactorsX Team & TaskX PROCESSX Leadership & Team DynamicX Purpose & PerformanceX OUTPUTSX ¶$FWLRQLQJ·	'HFLVLRQ0DNLQJX Outcomes X Patient, Clinical and Wider outcomesX Health EconomicsFindings: INPUTSX System & Organisation FactorsX Safeguarding Vulnerable Groups Act 2006 and Mental Capacity Act 2005 were most relevant and commonly mentioned national policy directivesX Local Guidelines mentioned less frequently; mostly to do with mandatory assessments required prior to decision-makingX CHOC MDT prepare and plan ahead for resource issues; e.g. closure of voluntary services and NHS staffing over ChristmasX Involvement of other services or availability of informal carers related to CHOC discharge; CHOC MDT unlikely to WDNHRYHUIURPRU¶WRSXS·RWKHUFDUHSURYLVLRQFindings: INPUTSX Team & TaskX Good skill mix for each CHOC MDT observed, but notable lack of 0HQWDO+HDOWK6HUYLFHV·representationX If no representatives from a service are present (e.g. no pharmacist), at times handing actions to them becomes more difficult and less effectiveX Information sharing before and during the CHOC MDT works well within the team, but is considerably complicated by fragmented access to various systems across organisations (which often results in missing information)X Caseload is characterized by older adults, multimorbidity and either the patients refusing assistance or family members complicating accessFindings: PROCESSX Leadership & Team DynamicX ¶'H)DFWR·leadership of highest status and most outspoken professionals (e.g. GPs, geriatricians). The chair for the meeting FKDQJHVHDFKWLPHEXWWKH\DUHUDUHO\¶OHDGHUV·OHDGHUVKLSLVstableX 7KLVPHDQVWKDWLIWKH¶QDWXUDOOHDGHUV·DUHDEVHQWGXULQJDgiven MDT, the process changes considerably (often more collaboration and discussion)X Dominance of the medical model. Non-medical professionals or those of lower banding less likely to take part in decision making; usually feed back knowledge and/or take on actionsX Overall, a smaller platform given to Social Care and Voluntary sector professionals to raise questions or suggest action Findings: PROCESSX Purpose & PerformanceX Overall observed purpose of the CHOC MDT appears to be topool resources and distribute actions most efficiently with the knowledge of other attendees (i.e. avoiding double-up)X Performance measures not overtly discussed, but some indication from team discussions that the aim is to prevent a crisis, stop preventable deterioration and getting appropriate and speedy input from relevant health and social care professionalsX Patients of the caseload discussed each week, to ensure frequent reviewX Absence of a pre-defined and finite caseload size X Action is handed out depending on suitability and (at times) availability of staff Findings: OUTPUTSX ¶$FWLRQLQJ·& Decision Making X 15-20 cases in most CHOC MDTs, but variation likely, and differences between locations present. X In each of the 12 observed MDT meetings there were new cases accepted, and existing cases closedX Commonly agreed actions were visits by CHOC members either for assessment, or treatment or bothX Assigned actions from previous week reviewed at each meeting, but in some cases the professional fed back not having gad enough time to address the given action / visit the patientX Administrators record overall agreements, but attendees make personal notes, tooX Responsibility implicitly left with the action holder, who is expected to feed back the following week / make electronic records. Findings: OUTCOMESX Patient, Clinical and Wider OutcomesX Patient outcomes not discussed overtly during the MDT meetingsX Decrease in demand on acute services/hospital admissions not evident directly from the CHOCs, but some discussion on avoiding inappropriate admission has taken placeX Clinical outcomes also not discussed overtly in many cases and not standardised. Individual clinical outcomes (e.g. absence of infection, vital VLJQV·LQGLFDWRUVVRPHWLPHVGLVFXVVHGX Wider outcomes only discussed as reducing duplication of services X Health EconomiesX Delays in providing a service often identified, nut seen as irremediableand a result of insufficient resourcesX Problems in care (such as service previously needed but not accessed) identified effectively. Resolution, however, is rarely straightforward or quick due to complexity of cases (either multimorbidity, unmet social care needs or refusal of services)X Quick and appropriate response to patient problems affected by   patient eligibility and staff capacity, but attempted whenever possibleTriangulating FindingsStaff InterviewsStaff QuestionnaireMDT ObservationsWhat Works Well?X Good MDT skill-mix, high attendance numbersX Voluntary Sector involvement to provide social prescribing and befriending servicesX Dedicated geriatrician involvement to provide specialist medical knowledge on the ageing process (due to high proportion of older adults in the CHOC population) X Dedicated administrative support to pool, update and distribute informationX Face-to-face format of the CHOC MDT meetings (according to interviewees, teleconferencing would not have resulted in sufficient rapport and trust among attendees)X Cross-organisational relationship and partnership building within the MDT format (respondents often spoke of newly developed trust and confidence in colleagues from partner organisations attending the CHOC)X Tailoring for the needs of the local population (e.g. inviting fire and rescue services where appropriate)What Could Be Even Better?X IT and information sharing between organisations (to allow for more joined-up working both within and outside CHOC meetings)X Intra-organisation delegation at CHOC meetings (even if regular attendees are away, a colleague would represent the discipline) to ensure action points relevant to the agency  are undertakenX Greater participation of Mental Health professionalsX More equitable participation in decision-making across attendees from different professions and organisations (notably, this would increase the length of CHOC MDT meetings)X More upskilling of staff to further improve performance and skill-baseX Staff workloads re-evaluated to ensure retention (so professionals are able to attend the CHOCs / avoid cancellations due to workloads)X Speedier investigation of patients and implementation of action (if the overall workload is more manageable)X Funding arrangement (continued funding crucial)Thank YouAny Questions? Not right now? Then please e-mail: S.K.Jaswal@kent.ac.uk@CHSS_KENT

Encompass Vanguard: Evaluating Staff & Manager Perceptions

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Encompass Vanguard: Evaluating Staff & Manager Perceptions

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