Shared Decision Making for Clinicians: What’s it all about? HEKSS: 3rd April 2014 Sofitel Hotel, Gatwick Nick Lewis-Barned, RCP Clinical Fellow for SDM and SSM Outline • • • • • • What’s the problem? How are we doing? What are SDM/SSM? Why support is there (just now?) Why the problem? What can you (HEKSS) be doing? What’s the problem? Introducing Premini • • • • 65 years old Type 2 diabetes for 6 years Angina, high BP, BMI 33 kg/m2 Currently taking Gliclazide 160mg bd, Metfomin 1g bd, Pioglitazone 45mg daily, Simvastatin 80mg, Aspirin 75mg, Ramipril 5mg, Bendroflumethazide 2.5mg, Lansoprazole 15mg • HbA1c 78 mmol/mol; chol 5.3; EGFR 68 Dilemma Diabetes is complex and dangerous / deadly There are effective treatments to reduce risk Only a minority take treatments Why? Do our patients…? Respect and value HCPs? Have relevant information? / Feel listened to/involved? Do what they are told? Take tablets as prescribed? Have outcomes as good as could be? Feel satisfied with care? How are we doing? …or… ‘…but we do that already!’ How are we doing in general? % Aus Can Fr Ger Neth NZ UK US Regular doctor always tells you about treatment options and involves you in decisions 58 56 43 56 63 62 51 53 Your clinician gives you a written plan to manage care at home 42 47 34 31 35 43 35 66 Commonwealth Fund International Health Policy Survey of Sicker Adults 2005&2008 … in hospital? % Want more involvement in treatment decisions Source: NHS inpatient surveys …in primary care The % of adults with diabetes (> 1 year) who report that they have had at least one diabetes checkup in the last 12 months 100% 90% 80% 70% The % who have had a checkup and report that at their checkup they ‘almost always’… 60% 50% …discuss ideas about the best way to manage their diabetes 40% 30% …agree a plan to manage their condition over the next 12 months 20% 10% 0% Primary Care Trusts … discuss their goals in caring for their diabetes The Health Care Commission Report 2007 Making better decisions - the dilemma Patients: unaware of treatment or management options and outcomes Clinicians: unaware of patients’ circumstances and preferences Poor decision quality Slide from Foundation for Informed medical decision making with thanks to Angela Coulter ‘Insanity: Doing the same thing over and over again and expecting different results’ Rita Mae Brown ‘We cannot solve our problems with the same thinking we used when we created them’ Albert Einstein What are SDM / SSM? … the principles Support for Self-Management (SSM) Shared Decision Making (SDM) Managing weight Monitoring glucose levels Starting cholesterol lowering treatment Joining a walking group Stopping smoking Taking COPD rescue medication Pain relief in hospital Episodic care and specific decisions Planned care and day-to-day decisions ‘ After all, when you seek advice from someone it's certainly not because you want them to give it. You just want them to be there while you talk to yourself’ Sir Terry Pratchett Key elements of SDM Patients and Clinicians Working together to select – Tests, treatments, management or support packages Based on – Clinical evidence – Patient preferences – (Each given equal value) Adapted from Coulter & Collins 2011 Thinking differently: specific decisions Patients: Bringing experience, personal values, knowledge and preferences Clinicians: Bringing best evidence presented clearly and skillfully Best decision quality (SDM) Slide adapted from Foundation for Informed Medical Decision Making With thanks to Angela Coulter Thinking differently: Long Term Conditions Community Health care system Resources and policies Health care organisation Self management Delivery system support design Informed ‘activated’ patient Decision support Productive interactions Clinical information systems Prepared proactive health team Improved outcomes The Wagner Chronic Care Model Long Term Conditions are different Self-management Hours with healthcare professional = 4 hours in a year = 8756 hours in a year Learning from Year of Care ‘The key to good outcomes’ is Engaged empowered patient Organised proactive system Productive interactions Based on: NSF for Diabetes (UK) Wagner Chronic Care Model (USA) Care planning – it’s a verb! ‘A care plan is at the heart of a partnership approach to care and a central part of effective care management. The process of agreeing a care plan offers people active involvement in deciding, agreeing and owning how their condition is to be managed’ Partnership working What support is there (just now)? We’re being asked … to do the right thing! The health and social care system must be shaped around the needs of the patient, not the other way round. Step by step over the next ten years the NHS must be redesigned to be patient centred – to offer a personalised service… …. by 2010 it will be common place. NHS National Plan, 2000 No decision about you, without you ‘Patients must be at the heart of everything we do, not just as beneficiaries of care, but as participants, in shared decision-making. Rt Hon Andrew Lansley CBE MP, Secretary of State for Health, 8th June 2010: 'My ambition for patient-centred care' As patients, there should be no decision about us, without us.’ NHS Mandate (Commissioning Board) Domain 2 2.4 …to ensure the NHS becomes dramatically better at involving patients and their carers, and empowering them to manage and make decisions about their own care and treatment. 2.8 …is coordinated around the needs, convenience and choices of patients, their carers and families RCP Position Statement Shared Decision Making (SDM) and Support for SelfManagement (SSM) refer to a set of attitudes, roles, and skills, supported by tools and organisational systems, which put patients and carers into a full partnership relationship with clinicians in all clinical interactions. The College recognises that patients and carers expect this to be the usual / default experience in their clinical interactions with Physicians and will work towards making this part of normal practice July 2013 Future Hospitals Commission: Core Principle 8 Working with, and empowering, patients is a fundamental aspect of medical professionalism. Shared Decision Making should be the norm… Care should be designed to facilitate autonomy, self-care and health promotion. Medical staff must acquire skills for shared decision-making and encouraging better self-management by patients. September 2013 So why the problem? …making sure we make it practical What does Premini need? Before the consultation Information Sharing and ‘Activation’ During the consultation Consultation and joint decision making Agreed and shared goals and actions After the consultation Follow up support Making decisions different(ly) What we do now ? Consultation Identify the problem Decide want to act Clarify and discuss options Work out what is right for the person Decisions Information Action ? Action What we might do Results in advance Identify the problem Agenda setting prompt Consultation Decide want to act Clarify and discuss options Decision support prompt Work out what is right for the person Decisions IT: clinical record of care planning Send test results beforehand Emotional & psychological support Collaborative care planning consultation HCP committed to partnership working Information/ Structured education Engaged, informed patient ‘Prepared’ for consultation Organisational processes Contact numbers and safety netting Consultation skills / attitudes Integrated, multi-disciplinary team & expertise Senior buy-in & local champions to support & role model Commissioning - The foundation Develop nontraditional support provision Identify and fulfil needs Procured time for consultations, training, & IT Quality assure and measure © Year of Care Partnerships What can you (HEKSS) do? Practice and skills Developing a core skill sets and tools – Attitudes - partnership • ‘whose illness is it anyway?’ • A meeting of equals and experts – Techniques • Consultation skills - new – Tools • Developing supporting information / tools • Preference / choice / decision aids Practice and skills Training – implementing the skill set – ‘Woven’ into physician training and assessment • Undergraduate • Postgraduate foundation /CMT training / Specialty • Consultant Physician training Learning by seeing, learning by doing – ‘Champions network / community of interest’ • Mutually supporting / developing • Demonstrating ‘how’ as a normal part of practice Further information: [email protected] http://www.rcplondon.ac.uk/what-wedo/patient-involvement/shared-decisionmaking
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