出版社：Utrecht University, Maastricht University, Groningen University
摘要：Background : New models of Integrated Care, such as ‘virtual wards’ are being piloted in Newham Community Services, East London NHS Foundation Trust United Kingdom. These services aim to keep people, living with multiple long-term conditions, well at home through the provision of coordinated inter-disciplinary care noting that the total burden of a person’s health expenditure over their lifespan will be concentrated in their last years of life. Effective care in the community requires comprehensive, safe, person-centred assessments that can be used sensibly by any member of the inter-disciplinary team. This is core to in identifying needs, collaborative decision-making, appropriate use of resources and service provision. Historically biomedical information has been emphasised over mental, social and in particular personal aspirations in assessments. The ability to organise information from diverse sources and approaches, within a common framework is a necessary, new skill for professionals working in interdisciplinary teams in order to develop partnership in the delivery of goals of care. Intervention : The Handy Approach is a novel interdisciplinary assessment framework. It was developed in March 2014, after a literature review and a baseline audit showing variation in documenting the aspirations of the people referred for care. This prompted a need for concise assessments that were safe and person-centred. Assessments cannot proceed until capacity to consent to care has been established. The brief framework spans five domains to direct the interdisciplinary assessment towards personal outcomes, highlight risks and to enable coproduced support preparation. These domains are mapped on the five fingers of the hand, as a memory prompt. The domains covered start with the thumb representing cognition, followed by consent (index finger), function (middle finger), setting (ring finger) and wishes/goals of care (little finger). Alerts include: any impairment in cognition, if the person is bed bound, and if they live alone. Person specific hopes for care were elicited through strength based approaches leading with the question ‘What matters to you?’’ The introduction of the Handy Approach was supported by weekly teaching on topics such as advance preparation in dementia; medicine waste; functional trajectories in the last years of life; coproduction and how to build highly functional inter-professional teams. This was delivered in five-minute sessions described as ‘flash teaching’, which was also disseminated by email with links. Evaluation : This approach was introduced in the East London NHS Foundation Trust from April 2015. The approach was tested using Quality Improvement methodology, in one of four interdisciplinary teams, which takes referrals from local general practices. Stakeholders involved in the evaluation included all members of the interdisciplinary team (comprising: Occupational Therapist; Physiotherapist; Psychiatric Nurse; Care Navigator, Social Worker; Care of the Elderly Consultant, General Practitioner and Community Matron). The aim of the approach was to improve the degree to which people who were referred for integrated care have all five domains of the Handy Approach systematically documented at their first assessment. Outcomes : Documentation of 110 cases was tracked between 29 March 2015 and 10 February 2016. During this period 63 people [57%] had the Handy Approach framework documented but there was turnover of most of the team members. Each new member was inducted into using the Handy Approach as it is easy to learn. From the 26 November 2015 until 10 February 2016 there was stability within the team. From this point onwards there was sustained use of the Handy Approach both in documentation and in presentation in 25 consecutive cases. During the duration of the intervention over 35 topics were covered in the flash teaching and qualitative feedback from the team suggests that they value this method of learning. Challenges included a predetermined template not enabling notes to be documented in the Handy Approach format and additional information needing coding such as clinical measurements. Conclusion : Our testing of the framework demonstrates that the Handy Approach can be an accessible tool in the interdisciplinary team to elicit and document the aspirations of people for whom they provide care. Sustaining this work will mean measuring experiences of how goals of care are agreed and delivered and through developing systems to embed timely feedback loops into practice.
