Embed Size (px)
Citation preview
Relationship Centred Practice
Relationship Centred Practice :
Every interaction is mana enhancing
An approach in which the client/whānau is empowered and has ownership over the management of their life and conditions.
The role of the health professional, is to influence, working in partnership with clients and whānau to support them with the knowledge, skills and confidence to live well in the presence or absence of symptoms
Who really controls the outcomes for the clients/ whānau
that you work with?
Is it you?
Is it a colleague?
Is it your inter-disciplinary team?
Is it a community provider?
Or is it the clients/ whānau themselves?
“Who really controls outcomes?”
“Who really controls outcomes?”
‘The customer decides whether to pick up the medicine the provider prescribes, whether to take it as prescribed, whether to share it with a neighbour, whether to split it in half so it lasts longer, whether to stop taking it in a few days, whether to exercise, what to eat, whether to drink too much, whether to smoke, etc. All of these things are determined by the customer and not always in the provider’s presence. These decisions drive outcomes related to chronic care, long-term care, prevention and wellness, which account for 75 percent to 85 percent of health care expenditures.’
Learnings from the Southcentral Foundation in Alaska where a whole-system transformation was embarked on in 1999
Source: Gottlieb, K., Sylvester, I. and Eby, D. (2008) Transforming Your Practice: What Matters Most (Nuka Model)
Source: Gottlieb, K., Sylvester, I. and Eby, D. (2008) Transforming Your Practice: What Matters Most (Nuka Model)
Relational Principles
Recognising people as assets: seeing people as equal
partners in the design and delivery of services, not
passive recipients of – or worse, burdens on – public
services.
Building on people’s existing capabilities: rather than
starting with people’s needs (the traditional deficit
model), relational services start with peoples capabilities
and look for opportunities to help make these flourish.
Relational Principles
Mutuality and reciprocity: RCP is about a mutual and
reciprocal partnership, where professionals and people who
use services come together in an interdependent relationship
recognising that each are invaluable to producing effective
services and improving outcomes.
Peer support networks: engaging peer and personal
networks alongside professionals as the best way of
transferring knowledge and supporting change.
Relational Principles
Blurring distinctions: blurring the distinction between
professionals and people/whanau who use services by
reconfiguring the way services are developed and
delivered.
Facilitating rather than delivering: enabling professionals
to become facilitators and catalysts of change rather than
providers of services.
Three experts
Person/whanau bring expertise about themselves, their own social circumstances, attitudes to life and risk, values and preferences.
Professionals bring coaching skills, emotional intelligence, knowledge of the effectiveness, probable benefits and potential harms of options.
‘The computer’ provides equality of access to records for service user and professionals, information on relationship-centred pathways, outcome measures and evidence based decision aids to help active partners make informed decisions, particularly where there are uncertainties.
Security – to feel safe physically, psychologically, essentially
Belonging - to feel part of a valued group, to maintain or form important
relationships
Continuity - to be able to make links between the past, present and future
Purpose - to enjoy meaningful activity, to have valued goals
Achievement - to reach valued goals to satisfaction of self and/or others
Significance - to feel that you ‘matter’ and are accorded value and status
To Build Trusting Relationships Everyone Must Experience
Individual Level : Support people/whanau to manage their own health and well
being
Informal Community Level :Engage with Communities to support individuals
Formal Community Level : Work with the third sector to develop new models of
support
Public Services Level : Partnership across public services around social
determinants of health, particularly housing
Health Service Delivery Level : Integrated and Coordinated community,
primary, secondary, tertiary care. Integrated Physical/Mental Health
Policy Level : Influence Government Policy
Building Trusting Relationships
The RCP Framework
Through working in full partnership, both clinicians and person/whanau can
achieve the outcomes they want.
The fundamental aim is a meeting of equals with the clinician supporting the full,
confident involvement of the person/whanau, to take responsibility for their own
health and well being.
Using the RCP framework will give both person/whanau and clinician a sense of
satisfaction with decisions made, a greater sense of personal control and the
best possible result in terms of improvement in health.
As equals, each brings something unique and deserving respect and attention.
The framework consists of seven elements, extending before, through and after
one of more meeting between the partners, each element informed by ongoing
reflective practise and continuous quality improvement.
Relationship Centred Practice Model
2-1
Step 1 Step 3 Step 4 Step 5 Step 7
Moving the
person/whanau toward
the shared goal
collaboratively in a
mana enhancing way
Step 2 Step 6THE
HEALTH
GOAL
CURRENT
SITUATION
PrepareShared
Agenda
Further
InformationDiscuss
Options
Agree
Way
Forward
Treatment
or Make
Change
Review
Outcomes
Key Enablers
• Hui Process
• T-GROW
• Making health easer to understand
• person/whanau Activation
Clinician’s Agenda
Key Enabler 1: Making things easier to
understand
Making health easier to understand has a huge impact on outcomes
Clients/whānau need healthcare services and information they can understand and use to make the best decisions for their health.
We also need to think about how we provide information and how we enable clients to understand how to access services and support.
Ensuring we use supportive, enabling and inclusive language can make a big impact on the consultation and outcomes resulting from the interaction
The language we use has a fundamental effect on the client/whānau.
NZ Health Literacy Review: A guide May 2015
People who struggle to understand
are less likely to use prevention services
have less knowledge of their illness, treatment, and medicines
are less likely to recognise the first signs of medical problems
are less likely to manage their long-term/chronic condition
are less likely to communicate their concerns to health professionals
are more likely to be hospitalised due to a chronic condition
are more likely to use emergency services, and
are more vulnerable to workplace injury
1,621,000 adult New Zealanders struggle to understand current health information
That is approx 35% of our population Kōrero Mārama, 2010
We as health professionals need to do more to ensure that we use
supportive, enabling and inclusive language, that our health
services are accessible, easy to use and understand.
Language
impulsiveness
socialise
Strep
agitation
Oranga Tamariki…….Tamariki Ora
Healthscape
KPIs
ADLs
PHO
Key Enabler 2: Hui Process
Greet our whaiora Discover our connections Why are we here? Closing the
Find a solution encounter
© All rights reserved without prejudice, 2016
Whakawhanaunga
tangaKaupapa
Planning
Poroporoaki
Closure
FOLLOW
UPMihimihi
2-1
Step 1 Step 3 Step 4 Step 5 Step 7Step 2 Step 6
Prepare person/w
hanau
Agenda
Further
InformationDiscuss
Options
Agree
Way
Forward
Treatment
or Make
Change
Review
Outcomes
Key Enabler 2 - The Hui Process
The RCP framework is enriched as it is underpinned by kaupapa Māori approaches to effectively engage and build relationships with whaiora & their whanau
Four key elements:
Mihi: initial greeting and engagement: to ensure health professionals clearly introduce themselves and describe their role and the specific purpose of the consultation to the person/whanau and whānau. (Steps 1 & 2 of the RCP Framework)
Whanaungatanga: Making a connection (engaging the connection with the broader environment, perhaps geographically and location to help understand an affinity with each other. The primary focus is connecting at a personal level with the person/whanau and whānau present. It is not ‘building rapport’. (Steps 1 & 2 of the RCP Framework)
Kaupapa: Explore the person/whanau/whanau experience and understanding of their symtoms attending to the main purpose of the encounter – focus moves to history taking and clinical task at hand.
Poroporoaki: clearly identify the finishing point of the consultation, and to ensure clarity about next steps for person/whanau and whānau.
Whakawhanaungatanga
Develop a relationship based on whenua, migration, whānau, or te reo – the whānau might have given you some cues during the mihimihion areas that you might be able to engage with them on.
Questions like ‘Where is home for your whānau?’, How often do you get back there..?’
‘I have been there...’ (say something about your time there) OR ‘Where do the majority of your whānau live?’OR Does the person have a Māori name? Check pronunciation if
unsure.Important Question – ‘How have your experiences been with your GP
or health services in the past?’ If there have been issues then?, ‘How can we ensure this experience is better for you and your whanau this time?’
(Adapted from Pitama, S; Maori/Indigenous Health Institute, 2015)
Step 1 : Preparation
The clinician has prepared the person/whanau by sending
them information or arranging a person/whanau education
programme.
The person/whanau education programme eg Kia ora Hauora
provides increased health literacy, self-management skills,
The clinician reviews the facts of the case, what might be
done and what is known about the person/whanau and takes
any steps needed to improve the chance of a good result
from the process.
Step 2 : Agreeing a Shared Agenda
Once a connection has been made the health professional works with the person/whanau to draw out what the person/whanau knows, understands and wants.
Exploring the person/whanau’s perspective is very powerful
It helps build a strong relationship and rapport
It enables us to gather excellent information
It allows us to make efficient use of the time
Agreeing a shared agenda
Person/Whanau is Supported to Ask three questions
What are my options ?
What are the possible benefits and risks ?
How can we make a decision together that is right for
me ?
Key Enabler 3: T–GROW Coaching Model
Topic
Goal
RealityOptions
Way Forward
Open-ended questions & reflective listening
Open-ended exploratory questions:
‘What’, ‘Where’,‘How’ & ‘When’
They invite a broader response and are exploring questions that create
an equal conversation
(# Tip – Avoid the ‘Why’ & “But’ question, as it tends to put people on
the defensive)
Reflective listening - using words to let the person know that you have heard what they have said or to check facts
TOPIC
Establishing the topic for the coaching conversation
Creating that initial understanding What would you like to talk about today? [avoid temptation to use ‘how can I help you?,
what can I do for you?’]
So you have been feeling more tired and you have been coughing more... Is there
something/anything else?
Give the person the opportunity to share all their issues
OR
We need to discuss your TB medication – which aspect do you want to talk about today?
‘Out of those things which do you feel is your priority?’
‘What were you hoping would happen/we would achieve today?’
GOAL
Outcome for the conversation
Find out what is important to the client and what their priority is.
How do we go about doing this ?
By asking open questions such as:• Out of those things which do you feel is your priority?’
• ‘What were you hoping would happen/we would achieve today?’
• What is the most important thing for you right now?
• What are the reasons it is important to you?
• Where do you want to be in 3 months time (6 months time) with this?
Active listening – really listening for the meaning behind the words
REALITY
Establishing what is happening right now – the reality of the
client’s context What do things look like at the moment?
How is this situation impacting you /your whānau?
What else might be impacting on your health (environment, wairua, hinengaro)?
Have you had any adverse health experiences?
What would you like to achieve?
What is preventing you from achieving this?
What do you feel you are ready to change?
Step 3 :Gathering further information
Further information may be required to help the health professional and person/whanau understand the situation and options. E.g. Results from X-rays, tests etc
Some of the issues that you may be presented with could be outside your expertise, they may even be non-health related.
Where possible refer to colleagues who will have the relevant clinical expertise, and when the issues are outside health, consider referring to the social worker or a NGO who will be able to help on other issues such as housing, employment, tax, debt, etc
Step Four - Discussing Options
Discussing options
When both the health professional and person/whanau are fully informed, they can discuss options as partners
Discuss options from the person/whanau’s point of view and all the available clinical options together.
The health professional supports the person/whanau to consider relevant alternative approaches, ensuring the explanation is in a language and manner that the person/whanau can fully understand.
Discuss the benefits and drawbacks of each option in the light of the person/whanau’s own situation .
Ask the person/whanau to reflect back to you the different options that you have discussed together & the pros and cons of each option, to check for full understanding.
OPTIONS
What is possible –
Get them to try and generate at least 2-3 options
Draw on their past successes –
What has worked well for you in the past?
What are the possible ways forward
What else could you do?
What else? What else could you try? What else? (if struggling in the options stage, go back to Reality Step – safety mechanism)
Discussing options – Shared Decision Making
Shared decision making is a process in which health
professional and person/whanau work together to select tests, treatments, management or support packages, based on clinical evidence and the person/whanau’s informed preferences.
It involves the provision of evidence-based information (where available) about options, outcomes and uncertainties, together with decision support counselling and a system for recording and implementing person/whanau informed preferences.
(Coulter A, Collins A. Making shared decision-making a reality. No decision about me, without me. London: King’s Fund, 2011)
Shared Decision Making
Finding out all the things that are important TO the client
What is the client’s priority?(resource dependant)
Clarify the expectation
Identify & share clinical agenda
Clarify the boundaries
Agree/negotiate what you will do
Enable person/whanau to ask 3 questions
Have I addressed these 3
areas
1. Have I helped the person/whanau
identify the options?
2. Have I helped the person/whanau
identify possible benefits and risks of those options?
3. Have I helped the person/whanau assess how likely the possible benefits and risks of each option are to occur?
Key questions to coach the person/whanaus to ask
1. What are my options?
2. What are the possible benefits and risks of those options?
3. How likely are the possible benefits and risks of each option to occur?
Adapted from: ‘Ask 3 Questions Campaign’ www.cardiffandvaleuhb.nhs.uk
Step 5 : Agreeing the way forward
Once the benefits and drawbacks of all available options have been discussed, the health professional supports the person/whanau/whaiora to decide what should be done to achieve a realistic and acceptable goal.
Together they agree a plan of action that includes whatever treatment and other changes in health behaviour will help the person/whanau/whaioraadvance confidently towards that goal and manage his or her health well.
WAY FORWARD
Action Plan
– Committing to action
– Ask the client/whānau to tell you the health professional, what they are
going to do in their own words.
So now we have discussed all the options and we have decided a plan going forward, tell me exactly what you are going to do?
When will you start?
Removing any roadblocks
Is anything going to stop you from moving forward with this?
Offering support
Accountability
Action planning and goal setting
Consider the following elements;
S Is the action or goal agreed specific
M Is it measurable and will you know it has been achieved
A Is it achievable and how confident is the person
R Is it relevant and important to the person
T Is it timed
E When will you evaluate how it went and agree next steps
R When will you re-evaluate / review
If ambivalence or confidence is an issue then
person/whanau Activation is important
Person/whanau Activation’ is a widely recognised concept.
It describes the knowledge, skills and confidence a person
has in managing their own health and healthcare.
Key Enabler 4: Person/whanau Activation
The four levels of Person/whanau activationSource: Prof Judy Hubbard, University of Oregon
Level 1
Starting to take a role
Have not yet understood that
they must play an active role in their
own or child’s health. Used to being passive
recipients of care.
Level 2
Building knowledge and confidence
Lack the basic-health related knowledge
and facts or have not connected this health
information
into their understanding of their
health and ongoing management.
Level 3
Taking action
Have the key facts and are
beginning to take action but may
still lack the confidence and skill to support
their behaviours.
Level 4 Maintaining behaviours
Individuals have adopted new
behaviours but may not be able to
maintain them in the face of life
stressors or health crises.
Small steps … one at a time…
How do I know where the person is?
Explore levels of activation, confidence and problem solving.
Find out about their beliefs about self management.
Listen for ‘change talk’- phrases such as ‘I tried to…’, I thought about..’
Acknowledge and affirm.
Be enquiring and interested. Give good amounts of time for response.
Resist the urge to give information, justify or problem solve.
What has been working well for you?
What have you been doing that is contributing to your health?
What do you know about living with…?
What ideas/concerns/expectations do you have?
What are your thoughts about what you can do?
Common Barriers to Change
Fear or anxiety of change or new things
Strength or enjoyment of old habits
Dealing with the pain
Difficulty in planning
No / poor support from whanau
Financial, transport, housing constraints
Procrastination/ too hard /too tired /can’t be bothered
Key Enabler 5 : Motivational Interviewing
The use of scaling:
Importance
Confidence
Using Importance scaling
Needs to be linked to a verb (action) & have explanation of anchors with neutral voice and body language
Eg. ‘On a scale of 0-10 how important is it to you right now to stop smoking with 0 being no importance at all and 10 being the most important thing in your life?’
Eg. ‘It sounds as though you are really fed up with your weight. I’d like to understand how important you feel it is to you to lose weight on a scale of 0 to 10, with 0 being no importance and 10 being the most important thing right now’
Exploring Importance
Exploring Confidence
There is huge value in separating importance and confidence.
Often importance is high, however confidence is low
Having this information provides a structure to move forward and support
people to identify and access the things they need to improve their confidence
Family and friends may assume that the person does not want to change and
this may cause conflict
Understanding and acknowledging that importance and confidence are two
separate factors allows health professionals, individuals, family and carers to
understand how they can best offer helpful and proactive self management
support
Decision Making – Motivational Interviewing
Don’t Change Anything Make some changes
Good Outcomes 1. What’s working for you
now?
4. What benefits would you
expect from changing things?
Not so Good Outcomes 2. What’s the downside
(short/long term) of what you
are doing now?
3. What’s the downside of
changing things?
We have talked about a lot of aspects – what is standing out for you here?
What might your next step be?Adapted from Miller, Rollnick and McDowell
Step Six - Provide treatment,
Make the Change & Poroporoaki
Treatment and other changes
The clinician does what is necessary to see through
what has been agreed, supporting the person/whanau at
each stage and paying careful heed to how his or her
views might develop.
The person/whanau makes the health behaviour
changes with support.
Step Seven - Review outcomes
Reviewing Outcomes-Following Up
In follow up appointments, the clinician and client assess the actual result against the chosen
goal, reasons for any difference and what if any other action is required.
Finding out how things went, affirming effort and exploring challenges
Questions like:
How have you gone with achieving this goal?
If the result has not been achieved explore confidence/ambivalence
What has got in the way of you achieving this goal, do you think?
How can I support you to achieve this goal?
Identifying challenges that the client/whānau has encountered and developing problem solving
skills to overcome these, helps build confidence and resilience and engages the person in
developing strategies that will work for them in the context of their own social environment.
Reflective Learning And Service Improvement
Service Improvement using small size PDSA cycles, introducing novel
aspects of service provision are key to success and sustainability.
This creates knowledge to inform and change practise for both teams
and individuals within their local service context.
The aim of this is to continuously refresh clinical practise with current
evidence to provide improved clinical and person/whanau-centred
outcomes.
It will be important for clinicians and multidisciplinary teams to
disseminate their learning through presentations, discussions of
professional groups and formal articles.
What is it not about ?
Role of the clinician is to:
Support the person/whanau to increase their resilience to improve their
own health and well being
Prepare self and person/whanau for interaction as an active and equal
partner, allowing them to bring their agenda and supporting them to
consider their agenda
Assess the ability and willingness of the person/whanau to manage their
own health and well being
Acknowledge person/whanau expertise and assets, including the actions
they are currently taking, effort made, their networks within community
and social context.
Role of the clinician is to:
Support person/whanau to identify sources of ongoing support within
community context and social care including coaching interactions by
third sector who support people to achieve non health goals and actions
that lead to increased well-being and better health
Work collaboratively with both the person/whanau and clinician agenda
Understand potential outcomes for person/whanau according a number
of ‘care aims’
Ensure person/whanau understands their condition
Role of the clinician is to:
Ensure person/whanau understands benefit and dis-benefit of potential
options
Support person/whanau to make decisions about options available to
them
Support the person/whanau in managing their condition
Provide effective treatment or ensure these are put in place
Support person/whanau to change their health behaviours where
appropriate
Review person/whanau outcomes and discuss further options as
necessary
Role of the clinician is to:
Agree or negotiate when no further progress is possible and transfer
care or refer on having explored appropriate plan for continued action
and signposting or agreeing re-access protocol.
Understand the likely outcomes for person/whanau by undertaking
routine clinical audit and review of the evidence base and findings of
clinical research.
Continuous engagement in service improvement to offer new
interactions
Report outcomes of clinical audit to service designers, engage in service
redesign activities-particularly to prioritise prevention
