Análisis de determinación ¿Qué variables influyen sobre las ventas de las tiendas Diconsa? 43

That all patients and professionals have the knowledge and means to navigate their way through the health and care system to access the services they require.

1. A range of services are in place and easily accessible to support the individual long term needs of individuals and their carers.

2. All individuals requiring rehabilitation/reablement/recovery should be able to access appropriate services regardless of their clinical condition and personal circumstances, ensuring that there is equitable eligibility.

3. Rehabilitation/reablement/recovery services should be proactive, rather than reactive, and goal orientated.

Feedback from the stakeholder events highlighted many of the excellent examples of rehabilitation/reablement/recovery across the region. However, national and regional process mapping initiatives have highlighted the fragmented nature and variation in provision of community rehabilitation services 25-27_{. Access to these community services is reported as frequently}

being reliant upon local knowledge with confusion for local referring services and even greater confusion for the people that require the services, leaving them disempowered.

It was agreed that there is no one model for successfully providing integrated care, the right approach will vary according to the local context. However, there is a need to transform services which requires a fundamental shift towards care that is holistically co-ordinated around the needs of an individual, rather than based around disease areas. Prevention and care that promotes maintaining independent living for as long as possible is required. In order to achieve this there is a need for true integrated working to ensure that the right mix of services is available in the right place, at the right time. This requires services across physical and mental health, social care, public health and

Rehabilitation, Reablement and Recovery…..It’s a

collaboration between the right individuals providing

the right result as agreed by the patient and the

persons delivering the care package. So there is an

underlying plan that underpins all the activities that

may be undertaken.

Patient quote

5.1

Vision:

5.2

Quality

principles

5.3

Rationale and

evidence base

the wider voluntary sectors to actively work together more effectively to deliver person-centred care.9

National Voices28 _{produced a series of statements, describing what people}

want from integrated care, under a number of headings, with the overarching statement being:

This narrative has been accepted by NHS England, the Department of Health, the Care Quality Commission and the Local Authorities Association. This narrative was also tested out locally in Dorset in March 2014 as part of their Better Together programme of work which found that the views of local people and local providers were also in accordance with all of the statements.

The components of care which all contribute to the overall desired aim of high-quality, person-centred co-ordinated care for people, focusing on maintaining health and independence are set out in figure 7. In this QGD the focus is on these components of care, focusing on individual need rather than specifying the service structures where care should be provided or who should provide it, which needs to be agreed locally.

I can plan my care with people who work together to

understand me and my carer(s), allow me control,

and bring together services to achieve the outcomes

important to me.

5. ACCESSING SERVICES

1. Needs assessment and risk stratification: People with high care needs should be comprehensively assessed in order to risk stratify their needs and ensure they are triaged to the appropriate service(s).

2. Information and access:

a. Commissioned services should provide clearly accessible information (in a variety of mediums) to ensure that all individuals, patients and professionals (from primary care, secondary care, social services or third sector), are able to easily navigate the system and access the services they require.

Figure 7:

10 integrated services to provide patient-centred care

9

5.4

Quality

requirements

9

support, control and choice at end of life

1

age well and stay well

2

live well with one or more long-term conditions

3

support for complex co-morbidness /frailty

4

accessible, effective support in crisis

5

high-quality, person centred acute care

6

good discharge planning and post discharge support

7

effective rehabilitation and reablement

8

person centred, dignified long term care

shif

t to

prev

entio

n and

pro-active care

10

in

te

gr

ate

d se

rvice_{s to provide pe}rson-

cent

red

b. Where possible, referral pathways via a clearly signposted single point of access or care coordinator/navigator role/ keyworker should be implemented to allow both people and professionals to be triaged to the appropriate services.

c. Providers of single point of access should have robust systems in place to ensure that all call handlers have sufficient knowledge and competence to perform their role, including a training and competency framework (which has been developed with input from the service providers who they take referrals for).

d. Service provision and access should be equitable across the locality so that each person has access to the same level of service regardless of where they live.

e. Robust information sharing processes should be implemented to avoid repeat assessments and ensure up to date knowledge is appropriately available for all relevant professionals.

3. Communication: All referrals should be acknowledged in writing and patients and referrers should be given clear information on waiting times for assessment and treatment.

4. Choice: Individuals should be offered information about the most appropriate services for them in order to make informed choices.

5. Timely: Services should be delivered in a timely manner that does not delay potential recovery for the individual or increase their dependency.

6. Duration: Treatment should be needs led, based on achievement of goals and patient outcomes rather than via predetermined service targets.

7. Seven day services: Where appropriate, services should be delivered over a seven day period in line with national initiatives if of benefit to the individual’s clinical and social needs.

8. Return to work: Individuals in employment should be fast tracked to a service with staff who have specific training in vocational rehabilitation facilitation to reduce the risk of employment breaking down.

9. Integration: There should be clear evidence of multi-disciplinary working and integration of services across health and social care to avoid repeated

5. ACCESSING SERVICES

Innovative practice example

Community Neurology Service (CNS) – Solent NHS Trust

A specialist multi-professional service for adults with the long term chronic neurological problems of Multiple Sclerosis, Motor Neurone Disease, Parkinson’s Disease and Traumatic Brain Injury. The service operates a care navigator review system. The aim of a care navigator is to act as the main point of contact within the community neurology service for the patient, their next of kin and other associated healthcare professionals. The care navigator also carries out the patient reviews. A red/amber/green (RAG) model is used to categorise CNS patients and help identify their levels of need and the review processes that are to be followed. Professionals can refer into the service through a single point of access and individuals can also self-refer direct to the team.

Contact: Sallyann Smith, Clinical Manager, [email protected]

Innovative practice example

Single Point of Access Service (SPoA) in Dorset – South West Ambulance Service NHS Foundation Trust

SPoA provides acute & community based health care professionals, including frontline ambulance crews, with a one stop telephone number to refer patients requiring ongoing therapy or support. The patient is able to be treated and cared for in their own home by the same team. Patients requiring urgent input for a service can be seen within 1 hour of the referral being made for them, thus preventing long waits for input. The service reduces unnecessary hospital admissions.

Contact: Lesley Holt, SPoA Manager, [email protected] 5.5

Innovative

practice

examples

Innovative practice example

Better Together Programme, Dorset CCG and Local Authorities

Development of integrated locality teams for health and social care with one member of the team acting as the individual’s care co-ordinator. The service will operate from 8am to 8pm seven days a week including bank holidays. Initial referrals into the team will be via a single point of access (SPA). Once on the teams’ caseload individuals can contact the service either via the SPA or direct to their care co-ordinator. The integrated care teams will enable planned personalised care and respond in a timely way to people’s urgent needs, liaising with urgent care services to secure appropriate timely assessment and treatment. Contact: https://www.dorsetforyou.com/better-together

Innovative practice example

Single point of access, Nottingham Healthcare NHS Trust

A communication and referral hub, open from 07:00 to 21:00, 7 days a week, which provides information about and access to a range of community health and social care services.

Single Point of Access is staffed by a team of experienced advisors who have a wide knowledge of local health service provision and customer care expertise.

Contact: http://www.nottinghamshirehealthcare.nhs.uk/our-services/ health-partnerships/bassetlaw-health-partnerships/single-point-of- access/

5. ACCESSING SERVICES

Data on system measures could include:

l The number of readmissions and avoided admissions Data on process measures could include:

l Monitoring the appropriateness of referrals made via single point of access (a system for providers to give feedback on the appropriateness of the referrals they receive)

l The time taken for care navigators to respond to queries from individuals/ family/professionals

l Time to treatment

l Frequency and intensity of treatment

Data on quality outcome measures could include:

l The individual/carer/family experience of accessing services, including experience of integrated/seamless care

l Referrers’ experience of accessing services

l Quality of life measure to include both physical and mental health (one possible tool is the EQ-5D-5L)

l Access to information about available services (link to Adult Social Care Outcomes Framework 3D – The proportion of people who use services and carers who find it easy to find information about support)

5.6

Quality outcome

measures and

Key Performance

Indicators

5.6.1

System measures

5.6.2

Process measures

5.6.3

Quality outcome

measures

FOOTNOTES

25 West Hants CCG Patient and Public Involvement Event 2013 26 NHS IQ Rehabilitation Commissioning Survey 2014

In document INFORME FINAL Diciembre 2013 Dr. Dante Ariel Ayala Ortiz Responsable del Estudio (página 44-52)