Live Better to Feel Better Programme (Previously Expert Patients Programme)

This education and peer support programme is aimed at people with one or more long term conditions who are finding it challenging to manage life with their conditions. This (non-disease specific) programme is a safe space for people to explore together how their conditions are affecting their lives and gain the confidence and skill to break the negative symptom cycle.

Those who have completed the programme will be more self-reliant and better equipped to work in partnership with health professionals.

The programme consists of 5 group sessions exploring management approaches to common practical problems as well as practicing underpinning skills like gaining insight, solving problems and communicating more effectively.

Trained group facilitators have long term conditions themselves and mentor good self-management practice. The session culminates in people producing their own self-management plan and the Community Wellbeing Service will be in attendance to signpost people to community resources in order to maintain changes after the programme. 

Half day self-management awareness sessions are also available.

The programme is also looking to recruit volunteer tutors and supporters for the programme for which we provide training and support. Professionals should consider offering this personal development opportunity to any of their patients with a LTC who are looking for a challenge with assurance of a supportive environment.

Please provide the patient with the Self-management Registration Form and/or Patient leaflet. All patients will be contacted within 2 weeks of receipt of referral for a discussion of their needs. People who opt for another type of SM support e.g. disease-specific education or community group support, will be signposted on.

For further information about the programme, host a group session in your practice cluster or signpost patients, the Live Better to Feel Better programme can be contacted on:

Patient Activation Measure (PAM)

Patient Activation describes the knowledge skills and confidence a person has in managing their own healthcare.

The concept of patient activation links to all the principles of person centered care - supporting people to recognize and develop their own strengths and abilities.

A growing body of evidence emphasizes the importance of effective self management of long term conditions. People who recognize that they have a key role in self managing their condition ( and have the skills and confidence to do so) experience better health outcomes. Yet the ability of people to do this can vary considerably from person to person.

It is in the NHS interest to understand people's  activation levels. It is estimated that between 25 and 40 percent of the population have low levels of activation (levels1 &2). This means they are unlikely to respond to the relatively sophisticated opportunities for self-management that we present.

Measuring activation gives healthcare professionals a starting point to  "meet people where they are" to support patients in ways appropriate to these individuals on their journey of activation.It shapes the agenda for the consultation, including exploring patient expectations and motivations.Evidence shows that targeted interventions can increase activation levels and that the least activated patients make the most gains.

Understanding activation across populations informs service commissioning which can be  tailored to levels of activation. Pathways tailored to activation levels enables targeting and allocation of resources to those who are less activated and confident about managing their own healthcare.

Conversely, it can help us identify patients with high  levels of activation: "expert patients." These individuals are the untapped resource in our health system with capacity to offer support and encouragement to others still learning how to self manage.

All of this will help reduce the pressure on NHS services, improve quality and ensure that resources are focused on those patients with the most complex health needs.

The Patient Activation Measure (PAM) survey measures an individual’s knowledge, skills and confidence to manage his/her health. Unlike other approaches used in healthcare today, PAM does not assess one’s behaviour discretely. Rather, the framework recognises that those persons who feel “in charge” of their health engage in a whole constellation of health-related behaviours. It is a global measure of an individual’s overall ability to manage his/her health. Further, it has been demonstrated that activation levels are changeable. With effective support, individuals can increase their level of activation over time. Knowing an individual’s level of activation provides insight into consumer self-management competencies, making tailoring support possible.

The PAM13 Questionnaire is provided under licence between Insignia, and Gloucestershire CCG as an NHS England affiliate site. It is a copyrighted document which should not be reproduced or used outside the terms of the licence agreement.

i. PAM Difficulty Structure

The PAM survey has a defined difficulty structure. As an individual proceeds through the statements, it becomes increasingly difficult to respond in the affirmative (agree or strongly agree). The items at the high end of the scale refer to behaviours that are more complex and require more diligent and sustained efforts to initiate and maintain over time.

ii. PAM Measures Activation

An individual’s activation is measured through the completion of the PAM survey instrument. The PAM survey provides two metrics for consideration: 1) a score, and 2) a level. The activation score is based on a 0-100 point scale, with most individuals having activation scores between 30 & 90. Scores outside of this range are unlikely and generally result from individuals responding “Disagree Strongly” or “Agree Strongly” to each survey item.

The activation score can be used to segment individuals into one of four progressively higher levels of activation. Each level provides insight into an array of health-related attitudes and the performance of a wide range of behaviours. The level is an indicator of an individual’s competency to take on new behaviours; and as an individual’s level increases, so does his/her self-management capability.

The activation score is the more precise measure (as compared to the level of activation) and is used to track individual progress over time. Even a gain in activation score of 3-4 points is meaningful; as this much change is associated with the difference between engaging and not engaging in particular behaviours. This nominal point gain, however, may not move an individual to the next higher level of activation

PAM levels should be used primarily to help the GP and practice nurse provide the appropriate amount and type of support to the individual. The PAM activation score is used to track progress.

Individuals vary greatly in their ability to manage their health and healthcare. PAM can quickly identify where an individual is in terms of activation. The activation level gives the GP necessary information to tailor support and begin to build the individual’s self-management capacity – starting with the very first interaction.

a. Read and Interpret PAM Results

It is important to understand challenges the individual faces from the individual’s unique perspective. The PAM survey is a useful tool to start a productive conversation with a new participant or obtain important information from existing ones. Reviewing the PAM statements, and using the individual’s responses as a conversation-starter can initiate an in-depth discussion that will jump-start the interventional process.

1. PAM Responses

Each statement on the survey provides the individual with a choice of five (5) different response options – Disagree Strongly, Disagree, Agree, Agree Strongly and N/A. These response options should be interpreted as follows:

b. Review the individual’s PAM & State the Conversation

First, visually scan the individual’s responses to the PAM statements and notice the pattern of responses. The most common pattern of responses starts with “Agree Strongly” or “Agree” and generally moves to the left as the individual progresses through the rest of the statements in the PAM survey. If the pattern of responses generally moves to the left as you read down, locate the first statement where the individual’s response was “Agree” (see table below).

Find out how the individual feels about the statement where they first responded with an “Agree” within the survey. The discussion might start with a statement and a question like this:

“I see by your response to this statement, you agree you can help prevent or reduce problems with your health. Tell me more about this/what this means to you.”

By starting the discussion in this open-ended and non-threatening way, it gives the individual an opportunity to talk about the successes, as well as any problems they are presently encountering. Often, when the individual describes why they responded to a PAM statement in a certain way, they will describe what they perceive as the key issues preventing them from successfully managing their health and healthcare.

The individual’s identification of their perceived barriers to making progress is very important information for you to have; it reveals what the individual believes are their key stumbling blocks to being able to take steps toward positive action in their health.

Remember, it is one thing to observe another person for a short duration and then tell them all about what they are doing wrong and what they should do to correct their actions. It is quite another thing to have an individual feel safe enough to speak openly and honestly about what they already know they are doing and what they might be able to do to improve their situation. The barriers to action an individual can usually self-identify with the help of a skillful GP/practice nurse can later be used in a positive way as the basis for joint problem solving and effective troubleshooting.

c. Tailor Interaction

Research shows that when people start feeling more capable and in charge of their health (become more activated), they are more likely to change many of their behaviours. Thus, starting on issues the individual identified and encouraging taking steps that are likely to result in success builds motivation and confidence for making other, perhaps bigger (and maybe more clinically meaningful) steps later.

A key goal of the care process is to build individual confidence about health self-management. Asking individuals to take action steps they cannot successfully accomplish undermines their confidence, does not provide meaningful new information, and does not inspire skill-building. Jumping ahead or lagging behind one’s level of activation will simply create frustration for the individual and deter meaningful action. Understanding, empathy, and insight about where to start the intervention process are gained from the initial conversation, from the activation score, and from PAM discussion.

An Insignia PAM e-Learning package is accessible, covering introduction to Activation, the PAM tool and good practice in PAM administration.

Contact supportUK@insigniahealth.com to receive a login to the platform.  

Please see the Clinician Education section for presentations on PAM.

Pharmacy First - Minor Ailment Referral / Scheme (MAS)

As part of the Essential Services Contract with NHS England, all community pharmacies provide support for 'self-care' to patients and carers which includes providing appropriate advice to help them manage a self-limiting or long-term condition, including advice on the selection and use of any appropriate medicines. Most community pharmacies have consultation areas for private conversations and all discussions are completely confidential.

Community pharmacies who are participating in the CCG Enhanced Service 'Community Pharmacy Minor Ailments Scheme (MAS)', are able to provide some treatments for minor ailments, without charge, to people who fulfil the eligibility criteria. Community pharmacists are responsible for determining who is eligible under the scheme.

Please note: In accordance with the recommendations within the NHS England Guidance on conditions for which over the counter items should not routinely be prescribed in primary care which was adopted locally in May 2018, it is expected that in most situations the public will  purchase ‘over the counter’ medicine(s) to treat the listed minor ailments.

Please follow the resource link below for more information.

Please also see CCG Live page Community Pharmacy Services

Remote Monitoring (Telehealth)

The current contract with Baywater Healthcare Ltd, has been extended for a further 2 years, until March 2020 to provide existing services access to the new platform and also trial the new platform in other cohorts of care such as managing frailty and deprescribing.

Remote monitoring is the remote exchange of physiological data between a patient at home and medical staff to monitor their disease/condition. It includes (amongst other things) a home unit to measure and monitor temperature, blood pressure and other vital signs for clinical review at a remote location (for example a hospital site or GP practice) using wireless technology. Remote monitoring allows clinicians to deliver healthcare differently for the benefit of patients and healthcare staff.  It supports patients to learn, understand and self-manage their condition. It can have information and advice for the patient and individualised care plans set up.

Gloucestershire's specialist telehealth service is delivered by Gloucestershire Care Services NHS Trust Specialist Services team currently for patients under the care of the Heart Failure Service and the Gloucestershire Respiratory Team. The Heart Failure Nurses predominately use remote monitoring to assist with titration of medication and to stabilise unstable patients, whilst the Respiratory team use the system to closely monitor the patient’s condition following an acute exacerbation and hospital admission, and for unstable patients under their care. 

The wider remote monitoring programme allows clinicians and/ or pharmacists to adopt remote monitoring to manage high volumes of patients differently. GP practices and Community Nurses, Community Matrons and the Complex Care at Home Team, can use this programme to support the management of their patients with long term conditions e.g. Heart Failure, COPD and Diabetes and can include other cohorts of patients such as  people with frailty and cancer, who are at risk of admission to hospital.

By monitoring the patient's vital signs and responses to health questions regularly (daily, twice weekly etc), the clinician can quickly identify any deterioration and put in place timely remedial action to prevent a crisis and potentially an unplanned admission.

Patients living in Care Homes can also be considered for remote monitoring. An increasing number of Care Homes have multi-user devices making installations even quicker. 


How to gain access to the service:

If you would like to refer a patient for remote monitoring, then you firstly have to sign the PIN agreement form and return via the email address: bhltd.telehealth@nhs.net

You will then be issued with a unique log on to the live system.

As the platform is being updated, to comply with GDPR, each user will be required to update their details and be issued with a unique user PIN number. Please complete the PIN agreement form and return via the email address: bhltd.telehealth@nhs.net

You will then be issued with a unique log on to the live system.


New Referrals

Once you have your unique PIN, you can log onto the live system via the

Baywater Healthcare Online Portal: https://apps.baywater.co.uk/onlineportal/Account/Register

Alternatively you can refer directly using the referral form COMPLETED FORMS TO BE FAXED TO TELEHEALTH SERVICE DESK ON: 0844 415 9391

To arrange bespoke training for your team/ practice/ individuals, please contact Baywater Healthcare on: 0800 121 4524.

The national vision for remote monitoring – telehealth, is that every person with a long term condition(s) should be routinely considered to utilise appropriate technology to help them or their carers, as well as health and social care professionals better manage their condition. If telehealth is effective it should enable appropriate planned interventions for patients with greatest need and improve the quality/timeliness of the delivery of their care, thus improving or at least sustaining their health outcomes and reducing costs from avoided hospital emergency admissions and outpatient activity, or shorter stays in hospital.

The added advantages of remote monitoring from a patient’s perspective are their increased ability and confidence to self-manage their health condition(s). The Baywater Healthcare service can also facilitate the step down process for patients who want to maintain the management of their own condition.

Telehealth readings can signal a deterioration of a person’s condition, an under-lying infection, a cause for medication review / management etc. Patients may learn to recognise triggers that tend to derange the measures of their health that they are recording – such as stress triggering a raised blood pressure, or a rushed activity lowering their oxygen saturation level (SATs); then they can learn to avoid creating these triggers. Individualised management plans between the patient and their clinicians can allow the patient to start an intervention as previously agreed with their GP or practice nurse, e.g. for those with chronic obstructive pulmonary disease (COPD) to start taking standby prednisolone and/or antibiotic medication when there is a deterioration in their condition.

The Baywater Healthcare service has the following features: -

  • Supporting you to identify the patient cohorts
  • Supporting the creation of bespoke questions sets for all cohorts, including an existing set of established sets for COPD and Heat failure
  • Installation, maintenance and servicing for the patients equipment
  • Manage and triage alerts so you only see the true clinical alerts.
  • Provide a simple, easy to use, portal for clinicians to access their patients’ data quickly and on any device.
  • Ensure outcome data is recorded which enables the CCG to measure the success of the programme, by
    • Calculating the number of Hospital admissions avoided
    • Increase in case loads
    • Clinicians time saved
    • Improved patient engagement and reduced patient anxiety.
  • Patients become experts in their own condition / disease which gives them confidence to manage their condition and stay at home longer.

Please provide the patient with the Teleheath Information Leaflet here.

For more information please see the Managed Telehealth Services Brochure and Clinician guide or contact Baywater Healthcare on 0800 121 4524 or contact Helen Ballinger, Clinical Commissioning Manager on 0300 421 1994

Occupational Therapy

Adult Health & Social Care Occupational Therapy

Adult health & social care occupational therapy is provided as part of Gloucestershire's integrated community teams who bring together occupational therapists, physiotherapists, social workers, reablement workers and community nurses to work as one team to serve a local area.

Cheltenham Locality 01242 532 300
Cotswold Locality 01285 881 000
Forest Locality 01594 820 500
Gloucester Locality 01452 426 000
Stroud Locality 0300 421 6600
Tewkesbury Locality 01452 328 200

Alternatively contact the Adult Social Care Helpdesk for advice/to refer via telephone or email/fax this referral form to the number below. The helpdesk will then forward your request onto the relevant locality office:

Telephone: 01452 426868
Fax: 01452 427359
Office hours are 8am to 5pm Monday - Friday.
 
A patient leaflet can be found under the Patient and Carer Information and Leaflets section.

Hospital based occupational therapy services are provided by GHNHSFT at Cheltenham General Hospital and Gloucestershire Royal Hospital, please click here for further details.

Occupational therapy services for patients with a mental health issue or learning disability are provided by 2gether NHS Foundation Trust.  Please contact 2gether's Contact Centre for further details
Telecare

Contact Details

Refer via Adult Helpdesk- 01452 426868

Website- www.gloucestershire.gov.uk/telecare

Self Assessment website- http://www.staysafeandindependentathome.co.uk/

Telecare is a jointly funded service provided by Gloucestershire Care Services and Gloucestershire County council. It supports service users to ‘Stay Safe & Independent at Home’ by providing alarms and sensors to detect risks and emergencies within the home and community.

Telecare equipment is simple and easy to use. It can include:

  • fall detectors
  • bed and chair sensors
  • smoke and heat detectors
  • medication dispensers
  • memory prompting devices and texting services
  • GPS devices

Equipment can be linked to a monitoring centre with 24 hr operators who call for appropriate assistance when an alarm call is raised, by either phoning a ‘responder’ (e.g. a family member or neighbour) or the emergency services depending on the situation.

‘Stand alone’ Telecare equipment can also be used within the home to alert an onsite carer or family member to an emergency via a pager system.

  • Reduced hospital admissions- reducing the period of time that the service user could be injured or unwell could prevent the need for a hospital admission.
  • Reduced need for domiciliary care- by managing daily tasks independently including medication management and cooking, there could be less need for paid domiciliary carer visits.
  • Increased independence for the service user- managing independently with tasks can lead to increased confidence, self esteem and quality of life.
  • Improved management of health conditions- supporting with tasks such as medicating medication correctly can assist the service user to manage their health conditions more effectively.
  • Support for Carers- unpaid carers such as family members can be given greater peace of mind; meaning they can pop out for short periods of time or get a better night’s sleep knowing that they will be alerted if there is a problem.
  • Prevent or delay admission to residential/ nursing care homes- supporting with independence and managing risks helps the service user to live as safely as possible in their own home, preventing or delaying the need for permanent care.

Examples of people who could benefit from Telecare include individuals with;

  • Physical disabilities or long term health conditions
  • Dementia
  • Memory difficulties or mental health issues
  • Learning disabilities
  • Age related frailty

Telecare is a free service to service users who are eligible. Eligibility for the service is not means tested, it is based on the service user’s level of need and risk. Eligibility is determined upon the outcome of assessment.

To make a referral for an assessment visit contact the Adult Helpdesk on 01452 426868.

There is also the option of completing an online self- assessment at http://www.staysafeandindependentathome.co.uk/ – this service provides the option of signposting the service user to where they can privately purchase equipment, or alternatively sending their self assessment directly through to the Telecare Team to see if they are eligible for a free service.

Adult Social Care

Please follow the resource link below to access Gloucestershire County Council's information relating to health and social care for adults and older people which includes

Gloucestershire Wheelchair Service (GWS)

The Gloucestershire Wheelchair Service (GWS) provides for clients who have a clinical need to use a wheelchair indoors for longer than six months (due to  llness/disability).

Please use the referral form or call: 0300 421 7170
wheelchair.service@glos-care.nhs.uk or Glos-Care.WheelchairService@nhs.net
For repairs to NHS wheelchairs call: 01242 713 905

Further information including the Wheel chair Voucher Scheme can be found by following the resource link below.

Please note:
For short-term loans (less than six months), contact Integrated Community Equipment Service (below) or on 01452 520438.
For clients with ‘low needs’ requiring a standard wheelchair on a regular basis, please refer to a trained prescriber in the individual’s Integrated Community Team, i.e. Nurse/Physiotherapist/Occupational Therapist.

Community Equipment Service

Community equipment enables children and adults who require assistance to perform essential activities of daily living to maintain their health and autonomy and to live as full a life as possible.

Includes a list of community equipment available and contact details.

Patient Transport Services (to and from Hospital) (PTS)

Non-emergency patient transport services

Some people are eligible for non-emergency patient transport services (PTS).  These services provide free transport to and from hospital for people who have a medical need for it.

Please follow these links to patient information on elligibility, claims and contact numbers;

Additional patient information can be found on the NHS Gloucestershire CCG website by following the resource link below.

Complex Care at Home

The Complex Care at Home Team provide personalised support and care to adults who are losing their independence and resilience due to multiple/complex needs. This support will include care co-ordination, clinical expertise, health coaching and information and advice to help people manage their conditions, enabling them to access on-going low level support in the community.

The teams operate in Cheltenham, Gloucester and the Forest of Dean. Please see the below links to leaflets and referral forms.

Service Leaflet Referral Form
Cheltenham and Gloucester leaflet Cheltenham and Gloucester referral form
Forest of Dean leaflet Forest of Dean referral form

Please also see the Complex Care at Home video below.

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