The Programme of Care Approach TOP

The eCHIP project has used concepts from the CEN European Standards for Health Informatics ETC251 - to develop the model for consistency across all AHP and Community Nurses.

AHP Programmes  of Care address Problems and Issues identified by the client and AHP. These problems and issues will be resolved by the provision of one or more care plans.

 

 

 

Developing the Programmes of Care TOP

A professional working group with volunteers from each Health Board area were invited to a profession specific workshop to develop the relevant, Objectives (Actions), Health Issue (AHP) / Problems (Patient), Care Groups & Specialties for that profession. The group undertook to share the developing care programmes with their professional group within their health board area and to feedback their comments. Currently Dietetics, Occupational Therapy, Orthoptics, Physiotherapy, Podiatry and Speech & Language Therapy are reviewing their draft programmes. Once these summary programmes are finalised, defined and formatted they will be published on this site and have a period of consultation and agreement with the service about the implementation time scale.

 During the workshops it became clear that there was a need for further clarification of definitions from ISD and discussions are currently underway. Some of the terms and definitions have been placed within the Health Informatics Terms & Definitions section on this site.

 

Integrated Care Record Systems TOP

As part of the eHealth strategy and building on the development of ECCI, NHS Scotland is currently working on integrating clinical systems and defining the needs for specialist and generic clinical systems. No matter what decision is made, AHPs need to consider the level of information they are required to share with other clincians and partners (especially in Joint Future Working and Education) within a single clinical record system. This does not mean that all clinical information will be held in each system but that systems will be able to identify where the information is stored and the rights of the individual to access the information. Currently AHP clinical information is mainly kept on clinical record cards, which have little standardised formatting. Work has been ongoing through the NHS QIS AHP clinical effectiveness project in agreeing standard recording methods to evaluate practice across Scotland. As disease specific data standards work e.g. diabetes, stroke and cancer are developed, AHPs will have to agree standard profession specific datasets across Scotland for these disease areas. For further information on these areas see the eHealth section.

 While other clinicians will need information about AHP involvement with patients, it needs to be remembered that AHPs need to be able to access a variety of clinical systems for relevant clinical information about the health issues and problems they are working with. This information has now been identified for the 6 professions.

 Clinical Pathways TOP

The focus of the clinical journey is well recognised within re-design initiatives within healthcare. (NHS Modernisation agency). Previous AHP recording systems have allocated new patients and contacts to the institution patients are seen in. This has not made it easy to follow patient’s through their journey of care which may be with a community visit at home, several contacts within an acute care ward, followed by rehabilitation in a ward, day hospital and at home. The planned programme of care will cover the whole journey with measurable milestones of care plan outcomes along the pathway.

NHS QIS describes the patient journey as the pathway through the health services taken by the patient and as viewed by the patient.

 

 

An example of the programmes of care at one stage of the journey for an older person is attached . This pathway has been used within NHS QIS Healthcare Standards for older people to encompass complex patients journeys which requires involvement of different care professionals to resolve the health issue of a fractured femur and the reasons why the person had a fall. This does not reflect previous or future programmes of care which could all be summarised to reflect the total package of care.

 

Routes to Care TOP

The hip fracture journey identifies the start of the patient journey as an emergency event requiring emergency trauma management. Many patients requiring AHP involvement will be referred to the service by other health, social and educational practitioners and more commonly in the future by self referral. These people need to have the information that enables them to make the right decisions in accessing the service. Work being undertaken as part of NHS QIS AHP Clinical Effectiveness project with SCIMP about back pain will start to provide computer aided decision making and electronic    referral processing. AHPs need to become much more specific about the clinical conditions they are able to make a difference with and ensure that people are able to access the appropriate service at the right time. Prevention of chronic problems by early advice and minimal intervention is better than weeks / years of longstanding interventions. Through NHS QIS and MCN’s AHPs will have the opportunity to develop these indicators for intervention.

 

Data Standards and Datasets.

The need to specify the clinical information that should be recorded about clinical activity becomes more extant within Clinical Effectiveness Frameworks, Professional Accountability and Healthcare professional registration. Benchmarking and comparing services means that standardisation of the information being compared is essential. Thus the need for disease specific clinical datasets with supporting data standards becomes more urgent. Work has already been undertaken in Podiatry and Dietetics for Diabetic profession specific datasets which fit together in the overall clinical dataset for diabetes. Professional groups are urged to start defining and agreeing the essential data items that they need to have. Key questions when collecting any information are: -

“why is this information needed?”

“what will be done with the information?”

“can the information be derived in any other way?

 

The following diagram identfies the possible components of AHP clinical records. Areas in pink are currently under development, those in blue need to be identified by professional groups.

 Professional groups working through their special interest groups, with NHS Quality Improvement Scotland through the AHP Clinical Effectiveness Project have already started to address some of these issues - especially in Diabetes. Standard record fields and definitions will make retrospective audit, clinical effectiveness and benchmarking easier. This will help to acheive some of the direction of Building on Success that AHP services deliver effective value for money services, that make a difference to the people in Scotland.