shared decision making in transition feedback from aqua project – october 2014- february 2015
TRANSCRIPT
Shared Decision Making in TransitionFeedback from Aqua project – October 2014- February 2015
Case Study
ElleElle
Currently attending Special Educational
College setting – leaving June 2015
Currently attending Special Educational
College setting – leaving June 2015
Under care ofEndocrinology
Consultant
Diagnosis of Severe Learning
Disability/ physical disability
Loves socialising; meeting friends;
family; boyfriend – shopping / eating out/ Duke of Ed
Loves socialising; meeting friends;
family; boyfriend – shopping / eating out/ Duke of Ed
Elle would like to increase
independence – both in and outside
the home
Elle would like to increase
independence – both in and outside
the home
Diagnosis affects
mobility – Physio in
past/ risk of falls
O/T
Elle/ parents
would like to increase
mobility/ worried
about falls
Elle/ parents
would like to increase
mobility/ worried
about falls
Ready Tool’s completed with
Elle and mum as part of Transition
Assessment
Ready Tool’s completed with
Elle and mum as part of Transition
Assessment
EHC Process/ Social Service assessment
EHC Process/ Social Service assessment
Primary Care to take lead role in health support
19years
old
Successes in 2014Shared Decision Making/ Person-Centred Planning – we do that anyway but…Aqua Project has highlighted tools and the wider issues:
Motivational Interviewing
Ready Steady Go questionnaires
Parent Involvement
Strengthening links between Paediatrics/ Adult Therapists
Introducing measurement
for Shared Decision Making to provide
evidence
Aqua team learning/ problem solving together
Challenges to date:
System Issues
• EHC process• Individual Health Budgets• Clarity of Local Offer• Referral Criteria’s/
process affecting choice (including partner services)
• Transition/ Discharge on to Primary Care –how to influence SDM in Primary Care
Operational Issues
• Time to meet with/ joint work within the Team affects momentum
• Small cohort – data collection is minimal/ questions not good fit for our cohort
• Geographically dispersed/ diverse leadership arrangements
Addressing Challenges
System Issues
Difficult to address wider issues but:•Reviewing pathways between Paediatric/ Adult Therapy Services•Utilise Primary Care Access Team to introduce RSG Tools to Primary Care colleagues
Operational Issues
• Starting to embed Tools into the transition pathway (HEF and RSG)
• Devising Case Study due to small cohort – highlights complexity of transition for young people with Learning Disability across health and social care
Data collection:
Our Stakeholders
Adult therapy teams
Adult Service
Providers
NHS Continuing Care Team
CiCs Day services
(LA Funded)
Bridgewater Adult Learning
Disability service
Adult Bridgewater Services
Bridgewater Paediatric Services
ALD Transition social work
Children’s Social Work
Team
WWL Medical
Staff
SEND Team – Special
Education Needs Team
Community
Paediatricians
AQUA Shared Decision Making
Team
How do we communicate about the project with other key teams?Where recipients of healthcare and their families are more informed and involved in decisions, care is safer and more effective. Our Shared Decision Making Project, in partnership with AQuA aims to improve the way our clinicians engage, involve and interact with young people and their carers during the process of transition to ensure they are ready and well equipped, to make decisions about and access healthcare; supporting them with asking the right questions.