Proximity: Relationships, Records, e-Health - Person-centredness near and far

When data protection and confidentiality is debated "the need to know" is often wheeled out as a rationale for access to personal identifiable data.

See the following:
NHS Confidentiality Consultation - FIPR Response (esp. #18).
DoH, Confidentiality, UK

In addition, if I need to access the record of patient held at hospital 'x' from hospital 'y' what is the health care relationship that prompts and justifies this need?

At present visiting nursing and care homes, you go knowing that data capture and recording (care assessment) is a fundamental requirement. Having a secure laptop for community has long been promised. While tech solutions are available and implemented elsewhere, my lack of such technology prompts me to imagine a future visit. ...

Pulling up at the nursing home I walk up the drive, ring the bell. While I wait the new tablet device in its bag has already introduced itself to the home. As I am allowed in - my identity assured - the tablet continues its dialogue, it:

1. Downloads and updates existing active client data.
2. Downloads additional data as per the agreed dataset on the new referral.
3. Checks on items 1-2 with a review of recent prescribing for key psychotropic medicines.
4. It checks the most recent NICE, Cochrane evidence and reconciling the local care knowledge. (This may seem excessive at present, but come personalised medicine this will be crucial).
5. Will check on most recent clinical reviews and due dates.
6. The h2cm template is there ;-) ready to present the care domain summary for the general physician ... and possibly (roles?) the next care professional to visit this home and this resident.

The significance of relationships is usually denoted by distance. Personal space is rather obviously spatial. This is how we recognise (well one of the ways!) the meaning and significance of an intimate relationship. In care situations with individuals who are confused and potentially aggressive we are conscious of the need to have due regard and respect for that person's personal space. Spaces and boundaries have to be negotiated in a variety of ways and means. 

Health information technology has already made effective use of role-based access to systems. If we take person-centred care to the nth degree, proximity can also count as it does in mobile health (m-health). Whilst to effect a role is to be in a certain location and context (sat at the office PC in the hospital) roles are organisationally and politically defined. Proximity is also contextual and situated in other ways, my proximity to:

• the nursing home;
• the individual's room;
• the individual themselves.
• (and their relatives)

While telecare / informatics can deliver a dividend in remote care, it is essential that it can also demonstrably support person-centred care. The best way (clinically assured) to do that for many activities is person-to-person contact. Just because one-side of the relationship may not recall the encounter as little as five minutes after, does not mean that there is no value in sustaining the ring of the bell, the exchange of s-miles, the record that results and other background conversations.

Image source:
Gestalt - proximity
http://graphicdesign.spokanefalls.edu/tutorials/process/gestaltprinciples/gestaltprinc.htm

Shared Approach: 3 keys (and a certain conceptual framework)

Before we trip into 2011 let's make a quick return to 2008 and the three keys to the Shared Approach in mental health assessment [NIMHE, 2008] which are copied below.

In between each one I have highlighted how the Health Care Domains Model can contribute ...

1) active participation of the service user concerned in a shared understanding with service providers and where appropriate with their carers;

In the end (or at the beginning!) a model of care or assessment tool is only as good as the person using it.

To progress with key #1 there are in fact two locks to open. These are in the form of 'using' and 'user'. H2CM incorporates the individual from the outset. The model encourages consideration of the client's beliefs, preferences, and experiences ... Can the client and carer actually use the model themselves to help understand their needs, their care plan and interventions? Is there a homework exercise there for them?

Do they have capacity to decide? Do they need support - an advocate? How do we ensure the carer is factored into the care equation? Well, in h2cm that's through the social domain.

2) input from different provider perspectives within a multidisciplinary approach, and;

Do you know what "different provider perspectives within a multidisciplinary approach" look like?

Well just envisage that for a few moments. ...

A scary exercise, eh?

In order to take those different perspectives and integrate them a common framework is surely needed?

Artists are lucky they use perspective as an integrative lever on paper, canvas, or whatever medium.

Clients, carers, health and social care professionals need a canvas of their own, BUT one that is sufficiently generic and agnostic to be 'owned' by all. 

3) a person-centred focus that builds on the strengths, resiliencies and aspirations of the individual service user as well as identifying his or her needs and challenges. NIMHE (2008)

H2CM can support and foster person-centred care. The model is situated: there is one (changing) situation with the person at the center. Whatever the context -

strengths, resilience, stresses, vulnerabilities, aspirations, needs, challenges

- the care domains model is fit for purpose. Health and social care is dynamic, in person-centred care that focus needs to change accordingly. Our assessments and evaluations need to resolve the SCIENTIFIC, SOCIOLOGICAL, POLITICAL, INTERPERSONAL and SPIRITUAL dimensions of care while assuring the BIG picture.

Reference:
The National Institute for Mental Health in England (NIMHE) and the Care Services Improvement Partnership. 3 Keys to a shared approach in mental health assessment. London: Department of Health; 2008.
Available from: http://www.3keys.org.uk/downloads/3keys.pdf

Before you measure ....

Fitness-to-work tests to be reformed after criticism

- you check your tools:

You calibrate, validate and balance ...

strengths - weaknesses

functional - diagnostic

humanistic - mechanistic
individual - group
purpose - policy
practice - process

physical - emotional

person centred - policy centered
sad (?) - (you will be -) happy

Additional links:
How to assess happiness? A tale of three measures
WWF: Manifesto - The Politics of Happiness
Frank Furedi: Why the ‘politics of happiness’ makes me mad

Lean machine(s): chasing the contexts

There is a perennial game in health and social care called assessment and evaluation: the game could also be called 'CTC' - 'chasing the context'.

Relativity lies not only in the realm of physics and philosophy.

When I say relativity I am referring of course to the influence and impact of a health and social care situation from the constantly changing perspective of each of several different players:

• the patient;
• carer;
• nurse;
• doctor;
• manager;
• medical ward;
• community mental health team;
• commissioner.

Usually, the context collapses to a specific problem (a situation) and the players set to solve a care problem presented by an individual -

• a client, resident or patient;

and their -

• relatives;
• residential care home manager;
• residential care home staff nurse and team;
• community mental health nurse;
• medical personnel.

Context directs, dictates, and shapes health and social care theory, practice, management and policy.

This relativism can also subvert, sublime, confuse and stymie plans, common sense notions, creativity, innovation and management directives.

Like a tide this relativity picks us up and re-figures, re-paints and shifts the location of everything - including measures and how they are used.

Context is all! - so the saying goes. But context never wholly reveals itself. For that is another situation, another context, another side, another coin.

For context there are key defining parameters (location, diagnoses, risk, need, physical, mental, holistic ...) all of these are couched or spring from time.

So, the game calls for us and the tide teases us to measure and evaluate. This coast is never clear, but how long is it now? Where are the pathways now? Where will they be again?

As we travel (and travail) to and from this context to that - thresholds are also altered: up and down and always around; the way of life and ..... .

Image source:
http://www.esd112.org/edtech/no_limit/rs_archive.cfm

Book: "Outcome Measurement in Mental Health" Cambridge University Press

Outcome Measurement in Mental Health
Theory and Practice
Edited by Tom Trauer
Hardback
Published June 2010

In order to operate in an evidence-based fashion, mental health services rely on accurate, relevant, and systematic information. One important type of information is the nature of the problems experienced by recipients of mental health care, and how these problems change over the course of time. Outcome measurement involves the systematic, repeated assessment of aspects of health and illness, either by service providers, service recipients, or both. From outcome measurement clinicians and service recipients achieve a common language whereby they can plan treatment and track progress, team leaders and managers secure a basis to compare their services with others and to promote quality, while policy makers and funders derive evidence of effectiveness. This book will be an essential and practical resource for all members of the mental health clinical team as well as those responsible for establishing or managing services, and directing policy.

• Presents a global perspective on outcome measurement enabling readers to compare and contrast practices around the world
• Enables readers to identify the specific challenges presented in different groups and settings, the instruments to use, and how to use the results
• Emphasizes the relevance and use of outcome data to clinicians, to help them improve their effectiveness

Contents

Preface; 1. Introduction Tom Trauer; Part I. Outcome Measurement Around the World: 2. Mental health outcome measurement in Australia Jane Pirkis and Tom Callaly; 3. Outcome measures in New Zealand Graham Mellsop and Mark Smith; 4. Outcome measurement in England Mike Slade; 5. Outcome measurement in Ohio and the United States James Healy and Dee Roth; 6. The outcome questionnaire system: a practical application for mental health care settings Michael J. Lambert; 7. Outcome measurement in Italy Mirella Ruggeri; 8. Outcome measurement in Germany Sylke Andreas, Thomas Becker, Holger Schulz and Bernd Puschner; 9. Outcome measurement in mental health services in Norway Torleif Ruud; 10. Outcome measurement in Canada: one province's experience with implementation in community mental health David Smith; Part II. Outcome Measurement in Specific Groups and Settings: 11. Routine outcome measurement in child and adolescent mental health Peter Brann; 12. Outcome measurement in adult mental health services Tom Trauer; 13. Outcome measurement in older persons Rod McKay and Regina McDonald; 14. Outcome measurement with indigenous consumers Tricia Nagel and Tom Trauer; 15. Routine measurement of outcomes by Australian private hospital-based psychiatric services Allen Morris-Yates and Andrew Page; 16. Mental health outcome measurement in Non-Governmental Organizations (NGOs) Glen Tobias; 17. Outcome measurement in drug and alcohol services Maree Teesson and Mark Deady; Part III. Current Issues in Outcome Measurement: 18. Outcome measurement - applications and utility Tom Trauer; 19. Stakeholder perspectives in outcome measurement Tom Trauer; 20. Assessment of change in outcome measurement Tom Trauer; 21. Routine outcome measurement: perspectives on skills and training Tom Trauer and Tim Coombs; 22. A review of instruments in outcome measurement Tom Trauer; 23. Some economic and policy considerations for outcome measurement Rowena Jacobs; 24. Future directions Tom Trauer; Index.

http://www.cambridge.org/uk/catalogue/catalogue.asp?isbn=9780521118347

My source:
UK Routine Clinical Outcomes Network Forum

Carer's support evidence / measures and end of life care

The following e-mail was received this week from (Prof.) George Kernohan and includes correspondence with Mary A. Waldron, Research Assistant, University of Ulster (thanks to Mary for confirming the reference).

My responses to George's points are right justified, italicised.

<->

Peter,

I am beginning to find examples of Hodges’ model every day now.

Once you adopt the model as a framework George it does tend to frame everything,
so I am not surprised at your finding. Maybe there is a paper there too...

Today we had a second research meeting to consider a (more) rigorous attempt to evaluate the provision of ‘support’ to carers of people undergoing palliative or End-of-Life Care (EOLC). An area of care with a dearth of evidence. So we looked at one review from Grande et al. (2009). They say that:

There has already been considerable research identifying carers’ needs in EOLC. These include psychological support, information, help with personal, nursing and medical care of the patient, out of hours and night support, respite, domestic and financial help.^9,10,16–21 There is also a large body of research into adverse effects of care-giving, such as anxiety, depression, stress, strain, fatigue and mortality.^22–24
Given this strong evidence base, any further investigation into the prevalence of needs and adverse effects should mainly focus on under-researched groups to ensure that future interventions are sensitive to their specific concerns. This includes carers of patients with conditions other than cancer, including neurodegenerative disorders,²⁵ respiratory²⁶ and cardiovascular diseases,²⁷ to help us understand how differences in disease trajectories, awareness of the terminal nature of the disease and available support²⁸ translate into different carer experiences. Although carers of patients with dementia have been extensively researched, little is known about their needs during patients’ final phase of life.⁹ p.340.

(The numbers refer to references by Grande et al., I have extended the quote used here).

Thanks for this paper George (and Mary) which I will read in full.
I extended your quote to encompass some additional interesting ideas.

To move toward a plan for a more rigorous evaluation, I would like to use a simple framework: here we go!

I think I will be suggesting Hodges’ Health Career as a possible model.

:-) ! If I can support you in this George I am pleased to help.

This could provide a framework for all carer-focused interventions in a broad way. As always, it would imply that carers need to have their needs addressed in terms of science, sociology, politics and interpersonal needs. As I see it, the first step would be to ‘map’ the carers’ needs onto that framework (from publications, if necessary from carers themselves). The basic idea (I think) is that care should address the four quadrants:

• Science: (carer’s physical needs, information, instruction)
• Political: (policy that enables care for carer, finance, allowance)
• Sociology: (recognising that people need people, networks and “sharing” groups, story telling/hearing)
• Interpersonal: (psychological support, prevention of anxiety & depression)

Have you any thoughts or guidance on this “mapping exercise”?

Goodness, that's quite a question!

Plenty of thoughts George but not sure how meaningful ....
Basically, since a community mental health project in 1990s
I have always considered (as per standard approach of course) that a toolkit of measures are needed. Even when we start from that most basic of distinctions between demand and supply.

As per your approach if h2cm is considered as a circle, a spectrum -
(sometimes we must circle the square)
then (if holstic) the adopted measures should cover all the domains:

Political: (outcomes, carer, patient satisfaction, financial assessment (means testing), respite care frequencies, reviews)
Interpersonal: (mood, coping ability, anxiety, depression, sleep, HoNOS)
Sciences: (pain, general health scales, care complexity (measures?))
Sociology: (dedicated carer assessment tools, sociability - social network size, psychosocial measures... there are many out there)

George, I realise the above is a ragbag collection but - like yours - these are dimensions which can (must) be reduced. Now there is also emphasis on this area post Darzi and the 'new' quality agenda.

This will serve (and is serving) to emphasize the distinctions between measures:

Objective - Subjective
Quantity - Quality
Staff administered - Self (Patient, Carer) administered
Global/general - condition specific
Service centered: Primary care - Secondary care

While it is easy to spin dichotomies,
the NHS must (constantly) focus on this area whatever the policy emphasis:

NHS Information Centre: Measuring for Quality Improvement

NHS Information Center: What is happening on indicators for...?

NHS Inst. for Innovation and Improvement: Quality and Service Improvement Tools

Earlier this year I contacted the NHS-IC [enquiries at ic.nhs.uk] regards additional measures of quality suggesting that the health career model bears due consideration (research).

Mental health services (and others?) have recognised how the measures they use can be a chaotic, personally selected, preferred, legacy-mix of assessment tools. Dictated by Senior Nurses, Consultants, Senior Management and not the evidence base. Now these are assured (are they?) with purposed selection (a task worthy of an 'away day') and then supported with regular in-house training.

Last month Anne-Marie Osbourne-Fitzgerald, Clinical Development Nurse, with (her) Clinical Manager, Denise Banks (Cygnet Hospitals), met Michael Doyle (Univ. of Manchester & Edenfield Unit, Prestwich Hospital) and I one evening at the Trafford Center in Manchester. Our two hour+ discussion covered the health career model, documentation, approaches to formal assessment and future plans (aspirations!). In the time available we obviously only scratched the surface, but Mike and Anne-Marie brought along examples of their paperwork.

Mike demonstrated how the health career model can be used implicitly or explicitly. At the Edenfield Unit the domains are being used individually to make up what is a standard A4 portrait form. The model informs their existing documentation; rather than the explicit form of the h2cm with the 2 x 2 matrix.
(I have a MS Word version of the latter and must update this to other formats).

Legally, as we know if it is not written down, recorded then it did not happen.
Educationally however, the objective is also to get students - practitioners - to think - before they do.

Anne Marie's documentation example at Cygnet Hospital included The Recovery Star:

http://www.mhpf.org.uk/recoveryStarApproach.asp

As you consider the star's points against the domains of the health career model - where in the model are you?

Can this provide another means to define 'care pathway'? A way that is not masked, hiding behind political, policy rhetoric (and really service-centered)? There are without question some excellent tools available, so care needs to be taken not to re-invent the wheel - hence your literature search. In some tools the effort and engagement of patients, carers and the public is exemplary. It seems what is needed is a hybrid solution. There is no single measure.

It may not sound scientific, but the complexities of care mean that academics, clinicians and managers must resort to a pick'n'mix approach. There is a battery of evidenced tools each with their history, application context and issues log (Why not? Lack of the latter might denote that such tools are no longer in development / review). As a clinician also involved in training, managers need to listen and make some tough operational decisions. The comms 'traffic' between clinicians, their managers, and senior managers needs to improve even more. Since, just using the above as an example, the STAR approach may find us on a ramble in the humanistic domains, the constraints of the mechanistic domain prompts the clinician's to ask:

"If you want me to use this assessment tool, what other thing do you want me to put down?"

As we are all aware: There is only so much time in a day, week, month, quarter. ...

In follow up emails I directed Anne-Marie to -

http://www.p-jones.demon.co.uk/contexts.htm

If you scroll down there is some discussion and graphics I did quite a while ago. This deserves revision as per the rest of the website, but the ideas are there I believe which can inform your project George?

Back then - and here on W2tQ I have been trying to demonstrate the wide range of contexts to which the health career model can be applied. In our meeting that evening the well established Tidal Model was also noted. This has of course benefitted from specific development, as per research that has produced audit and evaluation tools (Stevenson, et al. 2002).

It might make a useful reflective article – or at least a conference presentation. Ideally it would lead us to a measurement or observation approach ...

I would relish the prospect of a paper George, or a conference presentation. Not just contributing as a co-author/presenter, but supporting and enthusing new authors. The 21st century belongs to our students. Hodges' model can act as 'stellar' nursery not just here in the UK and EU, but globally. And not just in our respective disciplines (mental health, palliative - end of life care, forensic nursing care), but in informatics - conjoining and championing the need for socio-technical perspectives.

In addition to the above and thinking before they do, all health and social care practitioners must be able to reflect after.

As one of the original purposes for the model in my initial interview with Brian Hodges, research work addressing these are much needed.

This conceptual framework can offer much in case formulation, evaluation, clinical supervision, patient, carer and public (health) engagement.

[In short -] Can we measure Hodges' model?

George K. (Prof.)

You started with a big question George and similarly here at the end.
We have to be able to do this. In the first instance taking apart your question - there are clearly several questions here:

PRACTICE:

Above you noted that:

This could provide a framework for all carer-focused interventions in a broad way. As always, it would imply that carers need to have their needs addressed in terms of science, sociology, politics and interpersonal needs. As I see it, the first step would be to ‘map’ the carers’ needs onto that framework (from publications, if necessary from carers themselves).

It would be interesting to consider the formal process and practice of dementia care mapping against Hodges' model. Perhaps the approach you seek is something similar? If carer's make use of self-assessments these e-documents might act as an input for text analysis tools? If appropriate you could also weight certain items according to the priorities of carers? This would build on other carer research adding validity to your 'final' objectives.

Carers and clients (patients, service users) can with due explanation, appreciate the health career model. The model has a role to play in health education. I can well imagine a proforma similar to the Recovery Star example above, but purposed for carers and underpinned with the health career model. We also need to remember the spiritual domain, which is collective.

Ultimately George, your question concerns our ability to measure holistic, integrated, person-centred, multidisciplinary care and to state the obvious: there is no single measure to do this. Several tools and approaches gathered within a conceptual framework might however provide an environment favourable for a hybrid measure to emerge - literally a cycle?

THEORY:

In the paper you referred to George - Grande. et al. (2009) state:

In parallel with the lack of empirical evidence, there has been a lack of theoretical and conceptual models for when and how support provision in EOLC should improve carer outcomes. To guide further research, palliative care may here benefit from drawing on models within other fields, such as gerontology, sociology or psychology. p.341.

I am biased, but reading the paper the potential of the health career model as a high level tool is convincing just from a 'disciplinary cross-match'. Intra-, interdisciplinary, metadisciplinary and transdisciplinary perspectives could be a focus. This in addition to the specific knowledge and practical domains of sociology and psychology and as the authors note models therein. I forget the reference at the moment (and will check), but I recall carers / family units being framed in terms of strengths and weaknesses. That is, events, characteristics and relationships impact on a family with either additive, subtractive or neutral effects. This would seem applicable here?

While Grande et al. (2009) note that the (informal) carer's role is hidden (and is routinely described in this way) I wonder if in palliative care there are other dimensions that accentuate this 'hidden, covert' role?

The politics of potential death and actual dying may be another factor the health career model can help illuminate in a constructive, enabling way? Health care, patiency, sick roles, caring are always mediated by 'politics'. Hence the need for a political domain in any conceptual framework that Grande, et al. may consider. On a negative front, the model might also illustrate alienation and related concepts?

In conclusion!

Thank you so much George and Mary for my being able to share your initial thoughts here and respond with some of my own. I hope this helps you take your work further? There may be a few points to follow, which I will add and as you have noted above there is much that could be done to take this further.

Peter J.

From: Waldron Mary [mailto:MA.Waldron at ulster.ac.uk]
Sent: 06 June 2010 17:49
To: wg.kernohan at ulster.ac.uk
Subject: Carers Support Evidence

George,

Jury's still out on the effectiveness of support interventions and programmes which support carers in palliative care. Not enough research. Lack of evaluation, lack of rigour, no conclusive research, but lots of policy advocacy of carers support and addressing of needs. Sample of lit attached.

Mary A Waldron,
Research Assistant,
School of Nursing,
University of Ulster.

Many thanks George and Mary for your ongoing interest, and to Anne-Marie, Denise and Mike.

Reference:

Grande, G. et al. (2009) Supporting lay carers in end of life care: current gaps and future priorities, Palliative Medicine, 23: pp. 339-344. DOI: 10.1177/0269216309104875

Stevenson C, Barker P and Fletcher E (2002) Judgement days: developing an evaluation for an innovative nursing model. J Psychiatric and Mental Health Nursing, 9(3), 271-276.

Stellar nursery image
My source: http://media-2.web.britannica.com/eb-media/60/21260-004-3C62CA58.jpg

As one chapter closes another opens ...

Even if that chapter number is 15, 20 or even the penultimate - when it comes to older adults entering or residing in residential and nursing care facilities this is not just an excuse for a euphemism roll call:

'the end of the road',
'Club Medicated',
'Eldergarten',
'the final chapter', ...

Residents and their families all too frequently find that care needs are not static. The book is far from complete and ready for review. Their health (and we had better add well-being) status changes constantly. A care home's ability to cope and meet an individual resident's care needs adequately in safety without comprising other residents and staff must be continually evaluated. A person's condition may improve psychologically and yet their physical health calls for more nursing care that is physically driven; or vice versa. Trying to anticipate care needs what can be several years in advance is very difficult.

It is one of those intangible questions - as to how many care homes carry dual nursing registrations and so will be able to provide not only the current level of care, but future elderly mentally infirm care needs if required. The reasoning being that an internal move is far less traumatic than finding a new home? So, what is the state of care moves?

If we have no information about this
then we know nothing.

What might this tell us about an individual's health career and the health career - likely care trajectory - of conditions such as dementia?

Of course our assessments are, and can only be determined (a keyword if there ever was one) in the here and now. This is the priority, while also trying to anticipate the future if we possibly can.

There is undoubtedly a great need for research here. Research that spans the many care dimensions which residents, their families, care home staff and other multidisciplinary team members must balance. These include quality of life, physical, mental and spiritual care, economics, demand and supply and our very notions of care quality and holistic care.

Only then - for all unique individuals - can we write an epilogue that befits each of those preceding chapters.

Image: M.C. Escher crystal ball

What's good for art students ....

Never take the stylus or brush
in your hand if you have not first
constituted in your mind all that you have to do.

Leon Battista Alberti, On Painting, 1435-36

My source: 16 May 2010, Visit to The British Museum, Italian Renaissance drawings.

Is this my excuse for taking so long with a new website?

How can maps provide motivation?

"The class of maps that go beyond navigation to consolidate thought and convey a message belong to the broader class of infographics that aggregate words and numbers in a visual medium. While charts and graphs are often used to show progress to a goal, nothing personalizes the objective like measuring status, and revealing shortcomings, on a map."

-- Matt Ball, editor, the Americas / Asia Pacific


My source: V1 Newsletter Volume 4 / Issue 13/ March 30, 2010

http://twitter.com/spatialsustain

HoNOS, checklists and semi-structured interviews

Mental health services not routinely (and formally) using HoNOS (Health of the Nation Outcome Scales) are gearing up with a push to implement the scale across services by April. HoNOS has been around for a long time almost 20 years so it is time it earned its keep. Perhaps high quality tools take time to emerge from the noise and chatter of the care marketplace? ;-)

Although they are available, I've been putting a presentation together to help get to grips with HoNOS in the role of a trainer. The evidence for the validity and benefits of using HoNOS is well established, with the HoNOS family of scales boasting global usage and development:

• HoNOS for working age adults
• HoNOS65+ for older people
• HoNOSCA for children and adolescents
• HoNOS-Secure for use in health and social care settings secure psychiatric, prison health care and related forensic services, including those based in the community)
• HoNOS-LD for learning disabilities
• HoNOS-ABI for acquired brain injury (ref.)
  

The number of assessment, intervention and evaluation tools available to clinicians AND managers begs the question (ironically): is there 'space' in the toolkit for yet another tool? If HoNOS can help establish a coherent currency for mental health commissioning beyond the block contract then this is most welcome. Mental health services need to move forward on several fronts. There is a timeline running with completion of this difficult task in its sights.

One set of guidance for HoNOS points out that:

The scales are not used as a checklist or semi-structured interview, but form a brief record of severity.

There is some succor there then, since Hodges' model is a checklist and a quad-structured interview there is still a role for a global conceptual framework.

There's nothing like a full and tidy set of tools!

Ref. http://www.gpsa.org.au/media/docs/mentalhealth/honos_information.pdf

DoH: Honos health of the nation outcome scales report on research and development July 1993 - December 1995

Additional links:

The UK Routine Clinical Outcomes in Mental Health Group

The NHS Information Centre: Mental Health Minimum Dataset

RCP references

Nursing and care homes: the new schools 4 basic nursing care?

I do not wish to denigrate the quality of care in nursing homes, as I've blogged previously there are others better placed to do that when needed. In some the nursing care is exemplary and this is evident not just in their inspection rating, but the morale of staff, the reports of relatives and local community plus other indicators - especially when you visit and use your senses. As a nurse you are duty bound to assess the quality of care wherever your practice takes you. In the homes where the care is very poor, there is no escape from that reality. The reality of poor care first hits visitors when they smell the home they have entered. If there is no escape for them - well what then of the residents and staff?

Now an extended and dedicated role for nursing home liaison within community mental health nursing has arrived* and taken root, this must say something about the quality of care in this sector (and not merely suggest a shortage of Consultant Psychiatrists)? Nurse, service managers and commissioners recognise that if they do not preempt the referral torrent (or trickle from some care homes!) then community teams will grind to a stand-still. Care homes need assistance even as private businesses in assuring their holistic competency.

If services do not stem that referral flow as a wave or otherwise, they will in turn become second rate first-aiders with no primary purpose. They will be forced to respond repeatedly to the same client RE-referrals, the same set of disjointed, fractured physical:mental:social health problems presenting in a series of unique individuals. And this is not person-centred care.

What the nursing home liaison role says is that here is one place we can locate the theory-practice gap, a skills gap and a lack of integrated, holistic person-centered care. Mash-ups may be desirable in the virtual world, but in care delivery - is that safe? Too frequently the mash-up of combined physical and mental health problems pass staff by. The problems go unrecognized, they are there: evident, but disguised; due to lack of comprehensive observation, life histories and despite the question and answer sessions at the gates (service interface). However it is described (e.g. single point), the specialisation of community mental health teams into memory assessment, intermediate, community mental health, ... depends on the vibrant management and quality of referrals.

Much is made of nursing homes registered as EMI (Elderly Mentally Ill) and their need for or access to a registered mental health nurse (RMN); but RMNs in turn rely on the ability of more junior staff to observe and accurately report the basic aspects of the resident's physical and mental state. If equity for older people in care is to be achieved, then although the care - nursing home sector is 'private' and a 'business' there must be an accommodation, a partnership when it comes to education and valuing time invested in these homes.

*Additional links:

http://www.careinfo.org/congress/pdf07/07par.1340q2-joannehirst.pdf

http://www.mentalhealthequalities.org.uk/our-work/later-life/communities-of-interest/care-homes-liaision-/hartlepool-care-home-liaison/

Image source: Neo - The Matrix http://www.dailygalaxy.com/my_weblog/psychology/

Activities of Daily Living ADLs and Hodges' model [1]

The Hodges' model matrix below lists some basic Activities of Daily Living. The intention is to read the table as per the numbers. In 1. - the sciences domain - is a list of basic ADLs, this represents my classification of 'where' these ADLs live within Hodges' model. This is followed by a qualification in the intra-interpersonal domain 2.:

2. While basic ADLs are typically designated as 'functional', that is related to physical abilities they are of course also very dependent upon mental health status. Including: mood, motivation, memory, orientation, confusion. Many ADLs are closely associated with disease and illness, which affects people's independence.	1. personal hygiene dressing - undressing eating and drinking toilet: (urinary and faecal) elimination (often taken for granted) transfers: e.g. bed to chair and back degree of mobility (sitting - standing balance)
4. We can appreciate the impact of the carer's burden by arriving here finally. The sciences, interpersonal and political domains weigh heaviest here, as the carer assumes responsbility for the care of another, themselves and often other dependents.	3. Assessment of ADLs covers aspects of safety and risk to SELF, OTHERS and risk of SELF-NEGLECT. Increasingly, however the emphasis is on self-care, independent living and strengths in the above ADL skills.

In further blog posts I will present a similar treatment of other ADLs with references.

Link:
"Activities of Daily Living Evaluation." Encyclopedia of Nursing & Allied Health. Ed. Kristine Krapp. Gale Cengage, 2002. eNotes.com. 2006. 30 Nov, 2009 http://www.enotes.com/nursing-encyclopedia/activities-daily-living-evaluation

Bee in my bonnet and a place to call home

For some years (over a decade) I've had a bee in my bonnet about the impact of relative-ly sudden house moves that older adults often make following sudden bereavement.

This prompted a first and no longer maintained website 'Beware Reflex Moves'.

This rather silent issue still stands and is arguably growing in volume.

There are surely a series of studies to be made here. Like most forms of life, the patient-nurse encounters of all those years ago have evolved: the ability of Jo(e) Public and their families to independently visit, select and move their relative into residential care is a new factor.

Self-funding frees up valuable resources as people can essentially circumvent the formal assessment processes of social services (and health), negotiating directly with the home of their choice for a place. This place may be many, many miles away from what was home. Amid increasing demand this arrangement works well much of the time. When it fails though, the impact is a personal and social catastrophe that can also reverberate across two health and social care economies. The person's original social services and their new location - that of their family.

Here the 'diagnosis' may not just be bereavement reaction / depression, but dementia too.

So, the advice remains beware of reflex moves.

Wish those bees had stayed in that bonnet - they might be safe now.....

Image source with thanks: http://www.flickr.com/photos/lelonopo/2378726643/

Squaring circles: Compressed patient care pathways = rich(er) patient experiences?

The use of Lean and Six-Sigma, their combination and other service improvement approaches has resulted in much more effective patient care pathways. A shining example is that of diagnostic medicine and subsequent out-patient appointments, apparently patients can attend for diagnostic services such as imaging and on the same day also attend for their first out-patient appointment. This saves time for all, with expensive imaging technology also proving its worth and RoI by working from 0700-2200.

Trust Boards are well pleased with such progress, but there is no such thing as a free lunch. Managers and execs know the lunch (diagnostics and imaging) isn't free, but quantitative aspects aside what does does this mean in terms of quality and assurance? Quality in the sense of:

• patient (and carer) experience;
• staff capacity to find and take advantage of patient learning (self-care, patient health career management) opportunities;
• assessment and evaluation of patient (carer) comprehension;

There is a circle to be closed by relating quality to quantitative aspects; such as, re-referral rates, re-admission, medication / treatment concordance, plus the infusion of intelligence from local and national patient related outcome measures [PROMS] to new patient journeys.

In information science there is the concept of information compression, taking out the redundancy - repetitive data in an image or text to save on processing, transmission, and storage. As Lean Six Sigma assists teams to remove tasks, processes that do not 'add value' then the result is a richer experience. The patient journey has in this sense been compressed. The patient has fewer hospital and clinic visits with fewer bus, taxi journeys, or they pay less in car park fees. Health personnel and specialists are primed to help and deliver services that really count.

What does this compressed - 'denser' experience - mean though? Does it mean that:

• patient's are exposed to more information (2-3 significant interviews / leaflets / instructions)?
• there is less time available for education, health promotion, info Px giving?

- or alternately:

• does this 'value packed' patient journey help by providing rapidly successive hooks - experiential threads to integrate patient (carer and staff!) learning?

It will be interesting to see answers to these questions and how extensive the scope of benefits are of these patient experiences across different care contexts.

Is there an optimal number for 'clinical encounters' before things start to go awry?

PROMS are quite specific (as they need to be initially), but amid richer and varied patient journeys there will be a need for other (national and local) measures. What about the extent and level of 'care complexity' and 'holistic care'?

Additional links:

Lesley Wright on lean thinking and respecting NHS staff, HSJ, Dec 2008.

NHS ready for PROM date. NDS News Distribution Service.

Image source: http://www.navyenterprise.navy.mil/knowledge/tools/sixsigma.aspx

Holistic Skills Assessment and Assurance

Just lately - by virtue of mailing list subscriptions - I've received several calls for research proposals and notice of workshops providing advice on how to proceed. In response let me just say this is 'frustrating' - as I'm not in a position to:

• (OK, on your marks! Get set! GO!) - formulate the real question;
• seek partners;
• put in a bid;
• and put conceptual frameworks for (global) health and social care on the map.

They deserve to be there. For me the really interesting note to take home here is that these potential research projects could be grounded in several disciplines:

• nursing;
• health economics;
• informatics;
• public health;
• public and civic engagement. ...

While universal in scope they (e.g. Hodges' model) are not the universal solution.

They can and must complement other tools and resources as the care agenda shifts to quality and the measure of quality.

More than ever the holistic reach of not only 1st-line but 2nd-line ... staff is going to be crucial to how well policy-bearing organisations carry their load.

As the (quickly formulated, rapidly fixed) physical and emotional bandages are renewed and re-assurances given, we realise that (ill-) health is not just a condition specific conundrum. Health is a melange of choices, multiple diagnoses, beliefs, attitudes, educational opportunities, concentrated resources and much more that are difficult to focus. Strange thing this notion of inclusion. At the end of the day it comes down to:

The art of focusing without focusing ... ?

Holistic bandwidth means that that the holistic skills demonstrated at any time will be dynamic and vary according to the viewer, the context (and there will be several), the care domain and of course the measure(s). ...

Additional links:
Measuring of health and health-related quality of life with the EuroQol-5D

Image c/o - Wordle - and based on this blog.

Transcultural health & Hodges model

Text by Larson et al. (2001) is presented below with a suggested placement of
Bradshaw's (1972) typology of social need on to the four care domains of Hodges' model:

INTERPERSONAL : SCIENCES
SOCIOLOGY : POLITICAL

Felt need: The needs as perceived by members of the group.	Normative need: The group fails to meet an objective, universalistic standard. Technical definitions of need such as the Australian National Mental Health Standards are examples of normative need.
Expressed need: Through their behaviour, group members have demonstrated a need, often by lengthy queues for services or failure to attend a service.	Comparative need: The group is demonstratively worse off than another group. Comparative need is usually demonstrated through routinely collected statistics, which is problematic for small ethnic groups whose identities are rarely recorded (p.336).

Bradshaw’s framework is still widely used. The important distinction is one between the ‘top-down’, professional-derived definitions of normative and comparative needs, on the one hand, and the felt and expressed needs, interpreted as the ‘bottom-up’ expression of experiences and attitudes, on the other (p.336).

See also Larson et al. discussion of 'thin' and 'thick' needs.

(The fact that this typology can be described in terms of 'top-down' - 'bottom-up' also highlights the socio-technical potential of Hodges' model.)

References:
Bradshaw, J. (1972). The concept of social need. New Society, 19(496), 640–643.
Larson, A., Frkovic, I., van Kooten-Prasad, M., Manderson, L. (2001). Mental Health Needs Assessment in Australia’s Culturally Diverse Society, Transcultural Psychiatry, 33(3), 333-347. Abstract.

The INTRAPERSONAL links page includes Psychology I & II, Mental health, Therapies...

The SOCIOLOGICAL links page includes Patients, Carers, Sociology I & II...