Shared decision making, personalised care planning and self management support Train the Trainers event;
Lynne Craven Kerry Hallam Alf Collins with thanks to David Pennington
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Shared decision making, personalised care planning and self management support WORK BOOK
Welcome Thank you for attending this event. We hope you find it useful and informative. Our aims during this event will be to help you to develop confidence in supporting organisations and individuals to embed the principles of shared decision making, personalised care planning and self management support into their everyday practice. This task is by no means straightforward - so please use the time that we have together well;
Be curious, challenge yourself and feel free to make mistakes. Above all, be yourself- leave your corporate clothes at the door and roll your sleeves up….
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Shared decision making, personalised care planning and self management support WORK BOOK
The context: Good care, bad care? We know when we experience good healthcare, a smile here, a gesture there, a nurse who seems genuinely warm and concerned or a doctor who seems to have all the time in the world to listen. We also know when we experience poor healthcare, a grumpy nurse or a doctor who seems hell-bent on telling us what to do.
How can we change this? Many policy papers have been written over the last 5-10 years, exhorting us to embed the principles of shared decision making, personalised care planning and self management support into health services. However, very little has been written about how to go about making it happen. This course is designed to help you understand how to support individuals and organisations to change their practice. It is designed to help you understand some simple underlying principles and then use them flexibly according to the need of the client group you are working with.
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What this workbook is for: The attitudes, skills and behaviours needed to practice shared decision making, self management support or personalised care planning overlap enormously. There are, however, some important distinctions.
You could use this workbook to help you to: •
Deliver an organizational development programme covering SDM, SMS and PCP for a healthcare team
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Deliver an organizational development programme covering SDM or SMS or PCP for a healthcare team
Those healthcare teams could be: • • •
a general practice team a primary care team such as a team of case managers a secondary care team
What are we trying to achieve? Our central thesis is that: • •
Relationships between clinicians and patients needs to change. Clinicians and clinical teams should move from being diagnosticians and treaters towards (also) being healthcare partners
Moving towards being a healthcare partner is a journey of change for many clinicians. Some will embrace the change, whilst some will resist. Resistance to change is normal and should be respected. It is part of the journey.
The journey of change Change happens. It is inevitable. Most of us thrive on change. Some of us fear change. Some of us resist or avoid change. Being in control of change is what matters to us. This workbook is designed to help us support individuals and teams consider change.
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Our time together During the event we will endeavour to ensure there is a balance of knowledge plus time to practice skills. We will be using the principles of adult learning, please feel free to contribute your own thinking as this will add only improve the workshop. This workbook has been designed to be used and complement the slide pack. You will find plenty of space to record your own thoughts/notes/actions.
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Shared decision making, personalised care planning and self management support
WORK BOOK Session One:
Introduction to group working
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Large group facilitation skills All teach, all learn Connected, evolving conversations preferable to Disconnected, dissolving conversations Parking lot for questions/challenges that could halt progress One person speak at a time. Propose boundary (‘no more than a minute’) Offer a point of view rather than impose a point of view Reflect (‘what I think you are saying is..’). Link and learn to move the conversation onwards (‘and I’d like to add that….’) Don’t be afraid to challenge. Consider prefacing challenges with ‘I have an alternative view’ or ‘I have a challenge’. Use reflections and link and learn (‘however’ is preferable to ‘but’)
Write down other tips for yourself here
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Two:
Shared decision making overview
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Your philosophy re: shared decision making Statement 1 Shared decision making between patients and professionals is a meeting of equals and experts.
Statement 2 Professionals are responsible for supporting patients to make decisions that patients feel are best for them, even if the professional disagrees
Statement 3 Professionals should routinely encourage patients to access independent information, and come prepared with their own questions and ideas
Statement 4 Professionals should routinely tailor information to individual patient needs and allow them sufficient time to consider their options
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Three:
Long Term Conditions: An overview, the challenge and the case for change
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How important:
How Important is it to you that; We support people with long term conditions to manage their own health and healthcare?
0
10
What led you to say that?
How confident are you that; You/Your service/the NHS support (s) people to manage their own health and healthcare?
0
10
What led you to say that?
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Four
Shared decisions about treatments: An overview, the challenge and the case for change
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Your own personal notes
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Five:
Influencing others
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Your stakeholder map
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Your thoughts about persuasive conversations
Your elevator pitch for shared decision making
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Shared decision making, personalised care planning and self management support
WORK BOOK Session 6
Care planning and self management support Overview, context, challenges
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What is self care?
What is self Management?
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Your philosophy; Statements: 1. The person with a long term condition is in charge of their own life and managing their condition(s) 2. The person with a long term condition is the main decision-maker in terms of how they live with and manage their condition(s) 3. The person with a long term condition is more likely to act upon the decisions they make themselves rather than those made for them by a professional 4. The person with a long term condition and the health care professional are equals and experts
On a scale of 0-10, how much do you agree with these statements if: 0
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totally disagree
10
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totally agree
Statement 1:
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Statement 2:
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Statement 3:
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Statement 4:
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What led you to this rating?
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Seven:
Reflections
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Your notes
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Eight:
Workforce and systems
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Workforce- who needs to be trained to do what?
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Systems Have two conversations; Mrs Smith is 56. She has diabetes and heart problems. She is overweight and depressed. Her blood sugar readings were noted by a nurse to be high.
Conversation 1: She comes to see her doctor, but she doesn’t know why.
Conversation 2: The clinic nurse told Mrs Smith her blood sugar result and what it meant. She suggested Mrs Smith see the doctor and asked her to fill in an agenda sheet beforehand.
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Nine:
Care planning and self care support Skills workshop
Part 1
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Negotiated agenda setting Skills • • • • •
‘What do you want us to talk about today?’ ‘What do you want to make sure we talk about today?’ ‘What should we focus on today?’ ‘What are your priorities for today?’ ‘What one thing should we talk about today that would help you feel we used the time well?’
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Compile the list by reflecting: ‘OK- let’s talk about your diet’
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Then enquire about other priorities: ‘Is there anything else/is there something else/what else shall we talk about?
• • •
Add to list as necessary Enquire again (‘anything else….’) One last question, if patient shows no desire to add to list –‘are you sure?’
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‘To do each of your concerns justice, why don’t we focus on the most important for you today- and then make sure we meet again soon?’
Clinicians Agenda; • • •
‘I wonder if we could/should also talk about……’ If yes: ‘Good- let’s do that’ If no: ‘OK- perhaps we can talk about that next time’
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Coaching matrix
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Factors that build trust Your notes;
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Skills •
Open ended questions- invite a story - ‘tell me about’
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Affirmations, normalisation - ‘You have done so well to try’ (affirming change talk) - ‘of course’, ‘naturally’, ‘why would you not..’, ‘many people in your position tell me similar things’
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Reflections - ‘You have told me that…’, ‘What I think you are saying is’, ‘What I heard was..’
•
Summaries- A package of reflections and agenda items - ‘You told me how challenging it is to become more active and lose weight and we have agreed that we are going to talk about becoming more active in our conversation today’
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Coaching thin slice learning 1. 2. 3. 4.
Introductions etc Ask trainee what skill Ask trainee confidence level out of 10 Ask trainee to tell role player the clinical scenario (or provide). Remind not too hard! 5. Check with role player they are happy 6. Ask trainee to tell role player what point in consultation they want to start 7. Set rules; trainee or coach can time out at any time 8. Coach time out when trainee struggles-or has missed vital skill 9. Use role player as primary resource- and the rest of the participants 10. Feedback using coaching grid at end 11. Practice till confident then cement with one more session 12. Re-evaluate confidence
Your notes on role play
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Ten:
Care planning and self care support Skills workshop
Part 2
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Clinical skills
Exploring importance • • •
Which is your priority for us to talk about today? Which shall we focus on today? Do you mind if I ask you a few questions about that?
‘On a scale of 0-10, how important is it for you to change your smoking habit right now?’ 0----------------------------------------------------------------------------------------- 10 Not at all important most important thing in your life right now • • •
What led you to say 6? What led you to say 6 and not 5? What led you to say 6 and not 7?
Low priority • • •
‘It seems that (the change) isn’t a priority for you right now’pause, use body language to invite comment ‘Is there anything else we should focus on?’ Or- if high medical priority (smoking for instance): - ‘could/shall we talk about that next time?’ - Or:’ let’s talk about that next time’
Exploring ambivalence • •
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Empathy - ‘It’s natural to feel the way you do’ Double sided reflection - ‘On the one hand you are telling me you want to lose weight, on the other hand (naturally) you like your food!’ Invite story (solid gold, killer question!) - ‘What’s good about carrying on eating the way you do?’
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Decision matrix
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Goal setting and action planning vignette Your notes
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Clinical skills •
Define the goal ‘I want to become more active’
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Support problem solving if goal is nebulous ‘So, you want to become more active- what could you do/ what comes to mind?’ ‘What else?’ ‘What else?’ ‘Which are you going to focus on?’
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Clarify objective You’ve told me you are going to walk more
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Support assembly of first weeks action plan
‘When will you start?’ ‘How many times will you walk in the first week?’ ‘Where will you go?’ ‘Picture yourself doing the walk- what could stop you doing it?’ ‘What else?’ ‘How will you manage that obstacle?’ ‘What else comes to mind?’ ‘What else?’
Check confidence On a scale of 0-10, how confident are you that you will achieve the first weeks plan?
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Skills to support goal follow up Your notes
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Shared decision making, personalised care planning and self management support
WORK BOOK Session Eleven:
Shared decision making about treatments
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What are the features of a good decision? Think of a decision of importance.
Write it down:
Write down things you thought about when you made that decision:
What were the features of the decision making process that were important to you?
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Osteoarthritis of the knee This grid is designed to help you and your clinician decide how best to deal with pain in your knee. Frequently asked questions
Pain killers
Joint injections (steroids)
Knee replacement surgery
Will this reduce the pain I have in my knee?
Yes, to some extent. If you decide to become more active as well, this may also reduce your pain.
Yes, you should expect good pain relief and reduced swelling.
90 people in every 100 who have this operation have good pain relief, 10 in a 100 still have pain.
Will this help improve what I can manage to do?
Yes, to some extent. You will need to plan to become more active as a result of any pain relief you get from the painkillers. Advice from a physiotherapist may help.
Yes, usually for a month or two. You will need to plan to become more active as a result of the relief you get from an injection. Advice from a physiotherapist may help
Yes, there may be some improvement in what you can manage to do - but it is unlikely that you will notice a large difference in your ability to walk or climb stairs.
Are there any risks to this treatment?
Pail killers such as paracetamol and codeine do not have serious side effects unless you take more than suggested.
If done correctly, the problems are rare. It is possible that you may suffer swelling or that the joint may be damaged. Allergic reactions occur but are rare.
Wound infection occurs in 5 in every 100 people. Blood clot in the leg occur in 2 in every 100 people. Sometimes this lead to more serious problems.
Taking antiinflammatory medication - like ibuprofen - lead to problems more often, for example, stomach bleeds and heart problems.
Risk from surgery rises if you are suffering from other health conditions, such as heart or lung disease, are a smoker or are overweight. The risks increase with age.
How long will I take to recover from surgery
You will not have surgery.
You might feel the pain of the injection for a day or two.
You will stay in hospital for a few days. Most people walk unaided after 3 months. Full recovery may take between 612 months.
What do others think about this treatment?
Many people cope well by taking medication, being more active and losing weight.
Many people manage well by having injections when swelling and pain cause problems.
Many are very satisfied after having a new knee. About 20 in every 100 are not satisfied and some wish they had avoided the operation.
Pain relief will last three or more weeks. You can only have up to 4 injections a year.
Most knee replacements last 15-20 years and many can last longer.
Will I need to have more treatment or surgery
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What are your thoughts about the option grid?
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1. Choice talk: •
coach; look out for these skills and use coaching matrix to feed back after the scenario
Mrs Jones is 68, She is overweight and complaining of knee pain. An Xray confirms arthritis. You have just told her she has arthritis. The options she faces include getting more active, losing weight, taking analgesics or seeing a surgeon with a view to an injection or possible surgery
1. Step back: Check there is agreement on nature of the problem. ‘we agree that there is a problem with arthritis in your knee….pause’ 2. Choice exists: Be explicit- many patients expect to be told what to do. ‘There are a number of things we can discuss’ ‘I’d like to share some information with you about your options- is that OK?’ 3. Justify choice and clarify partnership/support ‘We need to think about what’s important for you’ ‘I am here to help you think this through’ 4. Check reaction. Patient engagement may be evident- however if not: ‘Before we think this through in more detail, I just want to check that you are comfortable with us thinking this through together’ 5. Defer closure and emphasise partnership. Some patients want you to decide; however this will lead to a decision that is not informed by ‘what matters to them’ I really want us to come to a decision that’s right for you. To help us do that, why don’t we look at a little more information. Is that OK?
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2. Option talk Use option grid and following schema
Step 1.
‘Here is an option grid’ Tell them that this is a summary of the reasonable options
Step 2.
‘Please take a look at it’ Check they are happy to read it for themselves
Step 3.
‘Highlight the bits that matter most to you’ Supports them to guide the conversation
Step 4.
‘Do you have any questions?’ Focusses conversation on what matters for them
Step 5.
‘It’s yours to keep’ Reinforces that the information is theirs Remind them to look for other sources of information
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3. Preference talk, decision talk
Step 6
‘In terms of what you know about your options, what’s most important for you? An open question which invites patients to express their preferences; they may be most interested in risk, predictability, outcome, recovery etc etc
Step 7
‘To come to a decision that’s right for you, what else do you need to know?’ Ask if patients have knowledge gaps as a result of expressing their preferences
Step 8
‘Are we ready to make a decision about what’s right for you” An open question that invites reflection May be followed by ‘what else do you need to know’ Or:’ it’s natural to feel uncertain. Take your time.’
Step 9
Patient articulates decision. Affirm decision, reinforce partnership. ‘We agree that we’ll go ahead and…..’
Step 10
Check for confidence ‘On a scale of 0-10, how confident are you that this is the right decision for you?’
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Your action plan
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Who are you going to train?
How are you going to arrange the training?
What further support do you need from the SHA?
How are you going to support each other?
What else?
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Your notes
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