Supporting Anticipatory Care for Long Term Conditions
Advances in healthcare mean that more people are living longer with conditions which previously they might not have survived (Nolte and McKee 2008). They are grouped under the terms chronic disease, long-standing illness or the term used in this essay, LTCs. These are recognised as requiring on-going care and support, limiting what people can do and lasting longer than a year (SEHD 2005). LTCs cannot be cured and so the focus of care shifts to means which enhance functional status, minimise distressing symptoms and reduce exacerbations of the condition through secondary prevention (Nolte and McKee 2008).
LTCs are also characterised as common in older people, people living in deprived areas and among the Scottish population (SEHD 2005; Loretto and Taylor 2007). The picture is further complicated by the prevalence of people living with more than one LTC and the rise in chronic multimorbidity (Barnett et al. 2012). This epidemiological and demographic shift represents a significant challenge to governments and healthcare providers (WHO 2011). The challenge for healthcare providers is to improve the management of care of people with LTCs. Traditional healthcare models focus on care for people with individual diseases; people with LTCs need a broader approach (Nolte and McKee 2008; Barnett et al. 2012) whose development has been shown to improve the health of people with LTCs (SEHD 2005). It should include increasing support for self-management, greater focus primary care, and the recognition and management of vulnerable cases ( Audit Scotland, 2007; SEHD 2005). Greater emphasis on patient empowerment and closer alignment of health services to patients’ needs is being proposed (Barnett et al. 2012).
In its broadest sense, anticipatory care is defined as a health improvement efforts involving primary, secondary and tertiary prevention interventions which are conveyed within or in tandem with health care and including direct contact with target populations. Anticipatory care planning is basically proactive thinking (Tapsfield et al., 2015) and is regarded “as a philosophy which promotes discussion in which individuals, their care providers and those close to them, make decisions concerning their future health or personal and practical aspects of care” (Scottish Government 2011). This process allows constructive deliberation and recording of future healthcare needs and preferences prior to the deterioration of health. ACP gives individuals the opportunity to make informed choices about their health and well-being and engage in conversations with care providers about their concerns. This involves respecting individual choice and implanting dignity and care in practice (Parsons and Assin, 2014).
Long term conditions
The drastic increase in long-term conditions (LTCs) poses a big challenge to individuals, families, and to healthcare systems globally (WHO, 2014). LTCs are now the most common causes of morbidity, disability, and mortality in Scotland. The burden of LTCs continues to grow annually as its population continues as their prevalence rises with age, affecting about 50 percent of people aged 50, and 80 per cent of those aged 65. According to data from the Patient Team Information (PTI) nearly 47% of the Scottish population see a member of a GP practice team for a possible LTC ` in a period of one year, although it includes many patients with the capability to manage their conditions and as a result their quality of life is not affected. In the Scottish Health Survey, some form of health complications, long-term illnesses, or disability was reported among nearly 37% of the population, while another 11% reported having a condition that limits their daily activities.
Gray and Leyland (2012) reporting the results of the Scottish Health Survey 2012 show that the incidence of adult LTCs rose from 41 percent in 2008 to 46% percent in 2012. This increase is more among women whereby in 2008, 42% of women in Scotland were diagnosed with an LTC, a figure that rose to 49% on 2012. This is in contrast to 38% and 42% for men in 2008 and 2012, respectively (Gray and Leyland, 2012). Statistics also show that in 2012, nearly a third (32%) of the adult population in Scotland had a limiting LTC, with a high prevalence of limiting LTCs observed to be higher among women (35% ) compared to men (28%).
Barnett et al. (2012) note that the incidence of multiple chronic conditions is increasing rapidly as the population ages. This implies that unless morbidity is significantly compressed, the demand for long-term care will grow exponentially over the next decades as the population becomes old. This precipitous age gradient also implies that unless individuals with multiple LTCS have access to high quality of health and social care as those with a single LTC, the elderly individuals with multiple LTCs have a higher risk of receiving lower quality care compared to younger people with lower probabilities of developing multiple conditions (Allen and Glasby, 2010). Essentially, the rise of LTCs with age poses significant challenges regarding quality and accessibility of some forms of care. In Scotland, like elsewhere in the world, the increased incidence of multi-morbidity has critical implications for the healthcare system. Notably, as patients continue to lead longer lives the risk of developing more LTCs increases, which subsequently increases the complexity of care and management of these conditions (Wanless, 2002). Several studies indicate that elder individuals with LTC multi-morbidity have more physician visits, had longer hospital stays and inpatient bed days and used more pharmaceuticals (Gallacher, et al., 2014).
Given the high costs implicated in the care of patients with age-related LTCs, health practitioners, and policy makers that current heath care systems need to be transformed to offer more proactive care in the management of LTCs. Despite this recognition, patients with LTCs still receive extremely fragmented service, which in turn results in less than expected outcomes, care experiences, and costs levels (Goodwin, Sonola, and Thiel, 2013). In the last decade or so, Scotland has adopted unique strategies to support care coordination and promote effective management of LTCs. However, these strategies have regularly failed to accomplish their objectives. Moreover, there has been a knowledge deficiency regarding the best approach through which the Scottish health system can apply and combine the different strategies to remain proactive against LTCs. In a recent research in Ireland by Darker et al. (2011) established that key barriers to providing chronic care within the settings of general practice were the main cause of increased workload and a lack of sufficient funding for the management of chronic disease. Developing tools and models that can be used to identify and monitor patients who are at risk of developing long-term illnesses is one best approach to understanding and managing chronic disease in any population. Further, understanding the dynamics of chronic disease within a population requires social, and healthcare services requir better planning on health promotion, prevention and self-management strategies.
Health policy has been devolved to the four nations of the UK; since 1999 for Scotland and Wales and 2000 for Northern Ireland (Murray et al. 2013). Since then the promotion of self-management support for people with LTCs has been managed separately in the four regions. At a recent conference LTCs (Tackling LTCs, 2013) three themes emerged as influencing the future direction of self-management: the importance of an integrated team approach to avoid fragmentation and better reflect a true patient-focused approach to care; greater recognition of the social capital and asset that people themselves present in being able to manage their health; and the importance of risk-profiling to target patients most in need of intervention (Shippee, et al., 2015).
Much of the early discussion in Scottish policy documents addressed the change needed to develop self-management support as a national priority. The Scottish Government’s commitment to improving care for people with LTCs was set out in “Delivering for Health” (SEHD 2005a) in which clear drivers for change are set out, legitimising and establishing the issues outlined in the document as worthy of attention. Responding to these policy-drivers is the objective of policy-makers and in a top-down model of should also be the objective of policy-implementers. Change and its delivery and management are the underlying frameworks informing how policy should be taken forward. “Delivering for Health” (SEHD 2005a) sets out the following drivers: increasing patient expectations, shifting population trends and medical advances. These can only be addressed if health services change. Legitimising self-management has not been established through theoretical ideas drawn from policy implementation literature but through reference to the need to change and modernise: “The NHS in Scotland needs to change. Not because it is in crisis as some would have us believe – it is not; but because Scotland’s healthcare needs are changing rapidly and we need to act now to ensure we are ready to meet future challenges” (SEHD 2005).
The Department of health’s 1980 report showed that while the general health had improved as a result of introducing the welfare state, it was noted that there existed widespread health inequalities (Department of Health, 2012). Thus, it was established that health was reliant on the economic wellbeing of individuals. This is similar to the facts established by the Barnett et al., (2012), a report which indicated that people living in poor neighbourhoods develop LTCs 10 years earlier. The finding remains a big influence not only in England and Scotland and has therefore widely contributed to the political standpoint of health policy. In another report, The Health Divide: Working together for a Healthier Scotland (1998) it was equally concluded that economic inequality had a positive correlation with health. Thus, solid connections have been identified between LTCs, lifestyle and economic factors and health determinants (Scottish Government, 2009). Based on these findings regarding LTCs’ concerns the Scotland government has implemented policy driven strategies to counter their challenges in addition to planning for the future.
For instance, one such key policy is the Building a Health Service whose objective is to create a national framework for service change through the provision of an action plan aimed at providing solutions to changing health care needs in the country (Scottish Executive 2005). The policy proposed a balance shift in terms of care from hospital to community-focused interventions. It recommended for an integration system where both the social and health care are involved and for the emphasis to be on individuals and their health needs instead of being disease specific. Also, the report recommended an approach based on preventive strategies towards ill health, especially in poor neighbourhoods. Thus, it encouraged the reduction of ill health and inequalities through economic empowerment, and this shifted the reactive approach of health care. The policy projected the involvement of strategies that would maximise community services and rehabilitate health care through the provision of state of the art communication equipment that would enhance accessibility, effectiveness, and quality.
Another intervention that supported these proposals was the Better Health Better Care Action Plan which made a commitment to enhance healthcare quality, improve the general health nationally, and narrow the health inequalities. To realize its goals the plan proposed the establishment of a common NHS Scotland where all departments were required to work collaboratively, but with the focus being on the patient’s needs as well as share experience for purposes of improving care. Healthcare bearing in Scotland today is driven through The Healthcare Quality Strategy for NHS Scotland of 2010, which is founded on the findings of The 2007 Better Health Better Care Plan (2007) combined with the 2020 Vision which is focused on effective approaches for implementing the Quality Strategy. On major objective of the Quality Strategy (2010) is to provide the “highest quality healthcare services to people in Scotland.” It is focused on collaborative working with the intention of delivering effective, safe and person-centred care that is based on internationally recognised six healthcare quality dimensions. However, this policy remains the pillar of making health care provision and management better in the future. For instance, it makes it a priority to address LTCs and initiates approaches that will lead to a shift towards a multidisciplinary strategic approach tol health for purposes of minimising the progression and impact of chronic diseases.
Therefore, the common theme in these policies is the adoption of an approach that is focused on anticipatory care planning (ACP). Such an undertaking will help individuals to identify any worsening or progression of their LTC at an early stage. Further, it seeks to equip individuals with guidance, knowledge, and support that will help them to be confident when making choices regarding their preferred healthcare interventions as well as in the planning and delivering personalised care (Coulter et al., 2013; Healthcare Improvement Scotland, 2016; Loretto & Taylor, 2007). This relies on findings by Baker et al. (2012), who noted that self-management and home treatments play a significant role in reducing or preventing unnecessary hospital admission.
The self-care model
According to the Alliance for Self-Care Research 2006, self-care is defined as, actions undertaken by individuals to prevent illness, maintain their health, seek medical interventions, and manage the illness and related side effects of treatment for purposes of realizing admirable recovery, rehabilitation and management of a chronic illness and disability (Long Term Conditions Alliance Scotland, 2008). Equally, according to the Department of Health’s definition, it describes the actions taken by individuals or their families to remain healthy and maintain good physical and mental health (Department of Health, 2013). To this effect it involves the management of minor ailments and injuries; however, its greatest potential is more in the framework of the management of LTCs.
Challenges for improving self-care skills
Living in poor neighbourhoods, employment, the level of education, language barriers, cultural religious and sexual orientations, as well as age has been identified as the common barriers that limit individuals from accessing self-care services. Accordingly, they have been identified by the Alliance Scotland (2008) as equal barriers to self-care skills improvement. Accessibility must be improved so in order to enable disadvantaged groups to gain access to health care services and improve their awareness on health. However, improving awareness on health is a big challenge, and as a result varying opinions regarding how health literacy can be promoted have been identified.
For instance, the Expert Patients Programme’s (EPP) is an initiative whose key agenda has been documented as “establishing the principle of individual self-management and self-care as a recognised public health measure” (EPP, 2008). The program offers free training to individuals living with any recognized long-term condition. However, even with its benefit of cost-effectiveness, several limitations have been noted on the programme. In one study by Richardson et al. (2008), it was identified that individuals living in poor neighbourhoods were less attracted to the programme. Thus, noting that these neighbourhoods suffer the worst regarding education levels and employment they equally report the highest frequency of LTCs and hence, the Scottish Government is targeting these areas with increased self-care support resources.
Evidence from research indicates that self-care benefits highly outweighs evidence to the contrary and hence such an initiative should be supported. For instance, a report by the Department of Health clearly demonstrated that many patients are in its preference and are hopeful that the government will invest more in it (Department of Health, 2013). This resonates the government’s primary objective of making patients the key subjects in all health care interventions. Nevertheless, attention needs to focus on its effectiveness since various studies have identified that effectiveness is unlikely among patients who have lived with the condition for a long time. Finally, it is important to change how individuals with long-term conditions are managed and supported; however, it is more important to establish effective strategies to manage the demand.
Role of paramedics in supporting the self-care
According to statistics from the British Geriatrics Society (2012), nearly 95% of unplanned LTC-related care in England is delivered through primary care. Thus, continuity of primary care has been identified as an intervention strategy that might equally reduce acute hospital admission especially among the elderly (Goodwin et al 2013; Health Foundation 2011). Conversely, patients with LTC and their families greatly value co-ordinated care, continuity of care, and familiar clinicians, since they consider that discontinuity of care disjointed care affects its quality (Ellins et al 2012; Haggerty 2012; Health Foundation 2011; National Voices 2013; Roland 2013;; Ross et al 2011).
Indeed, a key indicator for enhancing care for individuals with LTCs is through the reduction of unplanned hospital admissions for “ambulatory care-sensitive conditions (ACSCs)” (Department of Health 2011). The high admission levels for ACSCs mainly indicates poor harmonisation between the established elements within the health care sector, especially between primary and secondary care. Any unplanned admission for an ACSC signifies poor quality of care, regardless of the quality of the episode management (Haley, 2011).
Based on this, it is evident that the role of paramedics is important since it reduces admissions but only when it is sufficiently managed and supported as an important element of a wider integrated care system. As noted by Mason et al. (2007), additional training for paramedics and supporting their services so that they can efficiently provide initial management and stabilisation of various LTCs, can reduce admissions, length of stay, and increase patient satisfaction. Besides, joint care practises with community services and local acute providers can significantly minimise the frequency of ambulance trips to hospital for older patients who have suddenly fallen or become acutely ill (Logan et al 2010; NHS Confederation 2010). Hence, it is judicious for communities to develop collaborative care practices with ambulance service providers as a means of reducing hospital admissions and enhancing out-of-hospital care.
On their part, ambulance service providers should be professionally managed and must ensure that all paramedics are trained and sufficiently supported. These measures will ensure that older patients receive quality health care services at the comfort of their home. Effective ambulatory care can deliver anticipatory care for patients with LTCs involves allowing speedy contact to professional assistance from experts and delivery of services through ‘chair-based’ ambulatory care clinics (Tian et al 2012; Staples, 2012; Swayze and Jensen, 2016 ). Based on this, the effectiveness of both those unscheduled care services and scheduled service providers’ needs to be enhanced so as to ensure that they positively give support to self-care approaches with the same desired outcomes. It is a fact that unscheduled caregivers are only in contact with these patients for a very short time mainly during episodic care or in acute health needs.
That said, there are various challenges encountered by paramedic in relation to supporting self-care. The key challenge is the unfamiliarity with patient and lack of pertinent patient information which affects their ability to make accurate medical decision. Other challenges include; lack of clinical registers ambulances, lack of adequate ways by clinicians providing care to LTC patients advising paramedics on the care plan, and that patients are vulnerable when making decisions regarding their health and desired medical intervention (Hauswald, 2002; Mason et al., 2008; Schmidt et al., 2000; Silvestri et al., 2002). However, regardless of these limitations, paramedics are important in supporting individuals to develop their self-care skills.
Self-care programmes are increasingly gaining widespread support, not only from the government but also from patients, patient support groups, and caregivers. Major approaches used in support of self-care are founded on widely recognized researches in the fields of behavioural, social care and science, and health. Accordingly, there exist many evidence-base strategies to support self-care regardless of occasional indication criticising the success of self-care support approaches for identified conditions and specialized needs. However, it has been noted that the implementation of a joined-up approach, especially in relation to training, time and resources. Accordingly, it has been established that it is important to develop a direct link regarding the knowledge and skills framework and their training. Also, the availability of technology tools that enable timely and use of easy-to-learn tools, for example, the 5A’s approach is another approach that will enable shared decision making as well as improve the general content useful to their profession (World Health Organisation, 2004). Thus, it is important to streamline the sector so that the services of self-care by both the planned and emergency and unscheduled services to ensure that neither overshadows the other. Finally, self-care awareness education should involve paramedics and ambulance personnel even though their contact with patients is minimal.
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