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Training in Holistic Health Assessments

Training in Holistic Health Assessments

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Training in Holistic Health Assessments

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  1. Training in Holistic Health Assessments Lucy McCulloch Workstream Lead – General Practice

  2. HHA Training • CONTENTS • Integrated Care – what are we talking about? • Older People’s needs • Overview of Registers • Overview of Holistic Health Assessments

  3. The Vision Healthier, happier and longer lives through a radical transformation of how professionalsand communities work together to provide integrated care and better value, with empowered citizens better able to look after themselves through supported self care.

  4. Southwark and Lambeth Integrated Care : a federation of health and social care organisations and communities supported by GSTT Charity

  5. The Mission Build community with assets, capabilities and skills to support self care. 1. • Ensure that people in Southwark and Lambeth reliably receive the right care in the right place at the right time. 2. • Ensure that we are treating the whole person with care centred around the empowered individual. 3. • Ensure professionals are best able to deliver this new approach. 4. • Ensure better professional lives for the staff we are working with. 5.

  6. What is our joined-up approach? Redesign services and care pathways A new system where we all think and work together differently IT & informatics How & what organisations are paid Governance across participating organisations Workforce & change in practice Holistic care: Older people Long-term conditions in working-age adults Engaging citizens, patients and staff

  7. HHA Training • CONTENTS • Integrated Care – what are we talking about? • Older People’s needs • Overview of Registers • Overview of Holistic Health Assessments

  8. Integrated care for older people is our first priority • Older people told us they want: I want to stay fit and healthy I want to stay out of hospital or care home for as long as I can I want to have longer to talk about my needs with someone who understands I want all my needs looked at – including my mental health If I have to go to hospital, I want to be assessed quickly and return home

  9. Activities of programme for Older People

  10. What are the key changes for older people’s care? • An holistic system to help people with complex needs • Identifying needs through risk stratification and ‘holistic health assessment’ • Case management • Community-based multidisciplinary team • Increased access to reablement • Support for earlier intervention on falls, infection, nutrition and dementia • Better urgent response • Telephone advice for GPs • Bookable ‘hot clinics’ • ‘Home ward’ and rapid response teams to avoid admission • Simplified hospital discharge process

  11. What is the community multi-disciplinary team? • Supporting case management • (clinical meetings every 2 weeks) • Improving the quality of care for local people (quality meetings every 2 months) Admin and IT support

  12. Benefits of Older People’s Programme Benefits as outlined within Integrated Care Programme Charity Bid Business Case signed off by Programme Board and Sponsor Group in Autumn 2011 End of year 3

  13. HHA Training • CONTENTS • Integrated Care – what are we talking about? • Older People’s needs • Overview of Registers • Overview of Holistic Health Assessments

  14. Overview • Overview of creating registers and carrying out HHAs

  15. Tip: See ICP Report in Practice Focus for list of eligible older people (Under ‘Local Audit’ click on ‘ICP Older People’ button) See Register Guidance for more information

  16. HHA Training • CONTENTS • Integrated Care – what are we talking about? • Older People’s needs • Overview of Registers • Overview of Holistic Health Assessments

  17. Overview of the HHA • The holistic health assessment has 3 parts: • Preparation • Assessment, which includes recording outcomes/onward referral needs • Joint agreement between the assessor and older person on the next steps

  18. Preparation tips • Send an invite letter to ensure the older person knows what to expect • Make sure you have what you need • Begin the assessment before the older person is there: • Reviewing the key background information so you know what to expect • Carrying out FRAX • Check last bloods • Review medication list • Check when medication review last done

  19. Remember to • Record your outcomes in the Template • Record patient agreement in the Template • Write down key messages for the patient on the Handout (Annex I), such as: • Your actions – refer to GP for medication review • Patient’s actions – book eye test

  20. Payment for and monitoring of HHAs Tip: See ICP Report in Practice Focus for these sections (Under ‘Local Audit’ click on ‘ICP Older People’ button) • Each month the Practice Focus software will enable you to check your HHAs are complete and ready for payment Click on these to see which patients