Transcript Presentation title - Health Foundation

Practitioner Development
Programme
Skills Workshop 1
Welcome and Introductions
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Tutors
All in group
Name and area of work
House keeping;
-Manage self
- All teach all learn
-Toilets
-Fire alarm & exits
-Refreshments
-Mobile phones
Successes & Challenges
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Share your experiences of signposting people with long term
conditions to the SMP
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Share your experience of the Self Management Questionnaire
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Share update action plan activating intervention
Aims Skills Workshop 1
During this workshop you will have the opportunity to explore the skills
which contribute to successful collaborative agenda setting including;
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Building the relationship & rapport
Establishing an empathic relationship
Co-producing the agenda
Eliciting the patient’s priority and expectation
Clarifying & negotiating boundaries for the consultation
You will also have the opportunity to consider how your team and services
work and how these processes impact your ability to successfully support
patients to self manage and identify ideas you have to overcome barriers
Programme aim – review
Safe, effective, timely,
person centred, equitable
and efficient
The nature of the
interaction
created by the structures,
processes and
behaviours that exist within
the system
Achieving improvement
by changing relationships
between people & health services
Patients, clients groups,
service users, carers,
families and communities
Both the people who work in
and deliver care services and
the wider system
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Co-creating Health.
What are we trying to achieve?
Our aim is to support people with long term conditions to develop
the knowledge, skills and confidence to manage their own health
and healthcare (to become activated).
Co-creating Health supports people with long term conditions on
their journey of activation
Compared with people at low levels of activation, people at high
levels of activation tend to live a higher quality of life, have better
clinical outcomes and make more informed decisions about
accessing medical services.
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Levels of activation
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The CCH Integrated Model
©The Health Foundation
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Health behaviour modelling
Biological
Emotions / Thoughts
Social / Behavioural
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Learning agenda
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Share something that is working well for you in supporting people who
live with LTC’s to self manage
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Share something that you find challenging/frustrating
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Record on flip chart
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Review list end of skills workshop 3
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Consider how the skills we cover can support you to find solutions to
your challenges
Three key Enablers for clinicians, patients & systems
Becoming an active partner
Making change
Maintaining change
Agenda setting
– Identifying issues and problems
– Preparing in advance
– Agreeing a joint agenda
Goal setting
– Small and achievable goals
– Builds confidence and momentum
Goal follow-up
– Proactive – instigated by the system
– Soon – within 14 days
– Encouragement and reinforcement
– Most challenging to achieve
– Key for maintenance & progress
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The CCH Integrated Skills Model
Exploration
E
Agenda
setting
Goal
setting &
Action
Planning
Planning
Goal
follow
- up
Problem
solving
©The Health Foundation
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Traditional v collaborative
•Information & skills are taught based
on clinician agenda
•Patient & clinician share their agendas and
collaboratively decide what information and skills
are taught
•There is a belief that knowledge
creates behaviour change
•There is a belief that one’s confidence in the
ability to change, together with skills and
knowledge creates behaviour change
•The patient believes it is the
clinicians role to improve health
•The patient believes that they have an active role
to play in changing their own behaviours and
improve their own health
•Goals are set by the clinician and
success is measured by them
•The patient is supported by the clinician in
defining their own goals & success is measured by
their ability to attain those goals
•Decisions are made by the clinician
•Decisions are made as a patient-clinician
partnership
Successful Co-Creation requires:
Exploration
Inviting patients to contribute their beliefs, knowledge and values
that are critical to co-creating a partnership approach to their
health and well-being
Supporting patients to explore their ambivalence and explore
decisional balance
Using exploratory skills to find out what is important to the
patient rather than considering what is important for the patient
Successful Co-Creation requires:
Planning
Clinicians and patients collaborating on goals of
treatment and the action steps that each will pursue to
build health, well-being and confidence
Exploring levels of importance and confidence
Supporting autonomy and choice
Exploring what will support this process and what
challenges and barriers might get in the way
Agreeing how and when to follow up
Successful Co-Creation requires:
Follow-up
Patient and clinician supporting self-management by arranging to
learn from the results of the action plan within a meaningful,
proactive timeframe and agree next actions.
Phase 1 experience has shown that timely follow up (preferably
within two weeks) is essential if patients are to continue to
translate intention into action, implement action plans, achieve
goals and become more successful confident self managers.
Current systems and economics require us to find creative and
sustainable solutions to these challenges.
Successful co-production requires:
Problem solving
Clinician and patient explore the challenges to self- management
and collaboratively identify possible solutions.
Clinician coaches patient to develop problem solving skills and
confidence for self-management.
Patients identify the support and services they need to achieve
their goals.
Organisations and systems develop/amend processes to support
successful SM and SMS.
The three roles
• Teacher - information & education
• Manager - acute & emergency
• Coach – collaboration, partnership, confidence
• We need a full‘tool kit’ of skills
• All roles have a place and a value
• We need to be confident to move in and out of the roles
• We need to consider the these roles in the context of our
professional responsibility, job satisfaction and self esteem
Skills list
•Reflection/Empathy
•Support autonomy & choice
•Explore agenda/priority
•Double-sided reflection
•Explore agenda: clarify
boundaries
•Explore ambivalence
•Invite goals
•Explore beliefs about selfmanagement
•Ask before advise
•Explore importance 0-10
•Problem solving
•Explore confidence 0-10
•Action planning
•Effective Follow-up
Learning & understanding the patient
perspective
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Exploring the patient’s perspective is very powerful
It helps build a strong relationship and rapport
It enables us to gather excellent information
It allows us to make efficient use of the time
Key skills that support us to do this are;
-Open-ended questions
- Affirmation, normalisation
-Reflection
-Empathy
Open-ended questions
Questions that cannot ne answered with a ‘yes or no’
They invite a broader response
They create a more equal conversation
-How…?
-What…?
-When…?
-Where…?
-Who…?
-Tell me…?
Avoid
Why…? Can be risky, it can make the individual feel
defensive and that they have to justify their answer
Affirmations, normalisation
Affirmations:
Look out for ‘change talk’ in patient story and affirm (‘you told me
you tried to change before- that shows great determination’)
Normalisation:
Helps patients feel validated, that they are not alone, and that the
practitioner has experience of working with people like them
‘Many people tell me a similar story’
‘Its natural to feel the way you do’
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Reflective listening
Using words to let the person know that you have heard
what the they have said or to check facts;
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So, you are saying…
It sounds like…
You were wondering if…
I hear you saying…
Non verbal body language is not enough
Empathy
Using words to let the person know that you understand or
are trying to understand how it feels for them emotionally
• Reflection … You seem [frustrated, worried, sad]
• Validation…Anyone would feel
• Partnership…I’d like to help
• Respect…I’m impressed by how you
Listening to change exercise
• Think of a change you are considering
• Groups of 3
• Interviewer, Observer, Interviewee
• Explore using (only) OEQ’s, reflection & empathy
• Switch roles
• Group debrief
Treat with care
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Never underestimate the value of empathy & reflection
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It’s the what we lose when we are busy, stressed or distracted
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It delivers a value to the patient and clinician and their
relationship over and above the basic exchange of information
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As we start in our working lives we often have a more human
gaze – as our knowledge and experience increase we adopt a
more medical gaze – as we realise the complexities of life and
illness and the difficulties people face with regard to health
behaviour change we seek to redress that balance
Co-producing the agenda
Use open ended questions, reflection and empathy to
explore everything that the patient wishes to cover in the
consultation, find out their priority and what they are
hoping will happen (allow time for their response)
• What would you like to talk about today? [avoid temptation
to use ‘how can I help you?, what can I do for you?’]
• So you have been feeling more tired and you have been
coughing more... Is there something/anything else?
• Give the patient the opportunity to share all their issues ?
• Use summary reflection to pull together
• ‘Out of those things which do you feel is your priority?’
• ‘What were you hoping would happen/we would achieve
today?’
Co-producing the agenda
• Gather this overview before funnelling down to detailed
information gathering
• Avoid the temptation to explore the chief presenting
complaint before eliciting all the agenda
• Do not fear ‘the list’
• The process is efficient and can be successfully utilised
within the time frames for a primary care consultation
• Helps minimise the late addition to the agenda ‘Oh by the
way’ , ‘whilst I’m here’
• Can be applied to all clinician:patient interactions
Co-producing the agenda
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Once you know patient agenda, priority, expectation
Recognise & share clinician agenda, priority, expectation,
inviting patients to acknowledge clinicians responsibility
• From my perspective the things we need to cover today
are.....is that OK?
• Other things I think it would be helpful for us to discuss
are....is that OK?
• I have some information regarding your test results that I
would like to share......is that OK?
Negotiating & clarifying boundaries
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When both agendas are known it is possible to negotiate and agree what is
to be covered in the consultation and to give just attention to other agenda
items at a later time or in a different way
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If medical agenda truly supercedes patient priority due to clinical risk, use
collaborative language to explain and negotiate
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Share your perspective and rationale
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Find common ground before proceeding
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Use language of focus, patient’s self interest
Empathic Bridge
A useful tool for refocusing if the consultation goes off track
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You need to know agenda, priority, expectation
Use the patient’s language
Link with And.....
Underpin with empathy
Back on track.....
Try to avoid using ‘But’ in this or any other situation
‘But’ negates all that has gone before
Consider your own response to statements that contain ‘but’
Example
I’m really sorry to hear you have had such a stressful time it sounds as if it
has been really tough for you.......
And..... I know you wanted us to cover your leg pain, your sleepless nights
and your increasing breathlessness....
And......That your breathlessness is your main concern and you wanted to
know if your heart is coping.......
So.... Is it OK if we focus on examining your chest......
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Beware?!
• All the skills; whose agenda?
• Collaborative agenda setting is the foundation for
successful goal setting
• Why might goal setting fail?
• What is important to the patient as well as what is
important for the patient
Examples of Activating interventions
•Results in advance
•Agenda setting sheets
•Patient held record
•Access to information
•Information sharing
•Patients attending SMP skills training
•What do we need to change in the way we work that will
support collaborative agenda setting and how might we do this?
Experiential practice
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Consider the skills we have covered and decide what you would
like to try
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Most useful to select an area for which you attach high importance
and have low confidence
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Safe environment to try things in a different way and seeing what
happens
Action plan & next steps
The skill I am going to work on;
(e.g. from the skills descriptor list)
The patient focused activity I am going to work on;
(e.g. finding out about patient education & support groups, testing support tools such as the confidence ruler)
The process I am going to work on;
(e.g. trialling agenda setting sheets, sending out test results in advance )