Transforming Care After Treatment and the Ayrshire Experience

Transcription

1 Transforming Care After Treatment and the Ayrshire Experience

2 The overall aim of the programme is to ensure that people affected by cancer in Scotland, are prepared and supported to live with the consequences of the diagnosis and its treatment. TRANSFORMING NOT TWEAKING

3 Recurrent Themes Navigation The Carers role Dealing with late effects Dealing with emotional legacy Return to work Isolation Dying a dignified death Return to normality Regaining control Information and communication Poverty

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6 There needs to be a cultural shift in the approach to care and support for people affected by cancer. We need a greater focus on recovery and health and well-being after cancer treatment. Simply doing more of the same will not deliver the outcomes or improvements required. If you always do what you ve always done, you ll always get what you always got.

7 Patients should be risk stratified Personalised care plans Information to meet individual needs Care coordination across care settings Rapid access to appropriate health or care professionals

8 The Recovery Package is a series of key interventions which, when delivered together, can greatly improve outcomes for people living with and beyond cancer. The interventions are: Holistic Needs Assessment and Care Plan Treatment Summary Cancer Care Review and Health and Wellbeing Events. The other elements are part of an overall ethos of supported self-management: Physical activity as part of a healthy lifestyle Managing consequences of treatment and Information, financial and work support.

9 TCAT Phase 1 Projects SCAN NHS Borders Enhance health & wellbeing by providing integrated support, relevant to individual needs & promoting independence & healthy lifestyles. NHS Lothian Evaluate the immediate & intermediate benefits of a recovery based approach supported by the implementation of the HNA & EoTS. (Prostate, breast, gynaecological, anal/rectal & lung cancer) WOSCAN NHS A&A Provide a streamlined & person centred service through the delivery of complete packages of care, supported by cross sector partnerships, navigational support, the ehna, EoTS, rehabilitation & Health & Wellbeing events. NOSCAN NHS Tayside To implement systematic HNA & TS (head & neck, colorectal & urology) NHS Highland Implement a dedicated web portal visible to both patients & clinicians & compatible with PC and mobile technology (bowel cancer)

10 TCAT Phase 2 Projects 15 projects across 3 networks all with potential to impact upon people with a diagnosis of bowel cancer. Examples: East Dumbartonshire Council - Lay the groundwork for an infrastructure to identify, support & empower people affected by cancer, which will help reduce social isolation, improve pathways following discharge from hospital, improving the co-ordination of the available support & establishing better networks. North Ayrshire Council - Support people affected by breast & colorectal cancer to build the skills & necessary confidence to return to employment or to pursure business opportunities through integrated employability support. NHS Lanarkshire - Provide holistic & structured cancer care reviews for people affected by cancer in primary care practices.

11 The Ayrshire Experience (So Far!) Phase 1: 2 Year Project (November ) Year 1: Breast Cancer Year 2: Colorectal Cancer Patient and Carer Panel Increased ability to influence change Involvement in decision making Risk Stratification at MDT (Breast Ca) Patient-led and clinic-led follow-up Rapid access to appropriate health or care professional when problems arise Education and Evaluation Share learning and encourage spread Challenge cultural thinking Improve services

12 The Ayrshire Experience (So Far!) End of Treatment Summary Improve care co-ordination across care settings HNA/eHNA (with support directory*) and Health and Well-being Clinic Personalised care planning Information to meet individual needs Shared decision making Supported self management from the beginning Promotion of healthy lifestyles Increased understanding of needs throughout the pathway and the impact of services, support, etc. Cancer Rehabilitation and Health and Well-being Events* Utilisation of teachable moments Focus on health and well-being (diet and physical activity) *Utilising resources currently available and strengthening partnerships

13 Activity Progress Output Recruitment* Full team from March 2015 Patient & Carer Panel* Est. 2014/ Active Members Risk Stratification Breast Ca - Sept 2014 HNA/eHNA* Health & Well-being Clinic* Breast Ca - Sept2014 CR Ca (H&WB Clinic Only) Breast Ca - Jan 2015 CR Ca July 2015 EoTS* CR Ca - July 2015 H&N Ca Cancer Rehabilitation* Staff training Aug Jan 2015 Est. March 2015 Education Evaluation Ongoing Ongoing >300 Completed 7 Completed 94 People Invited 16 Completed (CR only) 13 Level 4 Fitness Instructors Data Reviewed Mid-Sept 2015 *Challenges

14 Looking Ahead Introduction of the (e)hna - When is the best time to use the (e)hna in the colorectal pathway? Promotion of rehabilitation and health and well-being clinics. Measurement of impact - What impact has the changes had on service provision, partnerships, clinical practice, clinical outcomes, quality of life, health and well-being? Beginning of Phase 2

15 Ayrshire TCAT Phase 2 Project Phase 2: 1 Year Project (August ) 15 Business Awareness Sessions delivered across Ayrshire Utilisation of Macmillan Work and Cancer Toolkit Promotion of Employability Pipelines and other vocational rehabilitation services available locally through Health and Well-being clinics established in Phase 1

16 Debbie Provan