Compassionate communities in Primary Care Dr Julian Abel
Compassionate communities in Primary Care Dr Julian Abel Director, Compassionate Communities UK
Four good reasons why compassion is important 1. 2. 3. 4. Impact of social relationships on mortality Harvard and Glueck Studies of Adult Development – 1938 onwards Evolutionary history of social relationships in humans Outcomes from Frome, Somerset UK
1. Comparison of odds (ln. OR) of decreased mortality across several conditions associated with mortality. Social Relationships: Drug Treatment for Hypertension Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLOS Medicine 7(7): e 1000316. https: //doi. org/10. 1371/journal. pmed. 1000316 https: //journals. plos. org/plosmedicine/article? id=10. 1371/journal. pmed. 1000316
2. Evolutionary history of social relationships in humans • The presence of socialising hormones, including oxytocin, and biochemical cascades, physiology and social behaviour all point towards compassion being part of evolution, not just in man, the most social of animals, but throughout the animal kingdom. • Survival of the kindest is a much more appropriate term than survival of the fittest.
2. Harvard and Glueck Studies of Adult Development Robert Waldinger George Vaillant • There was a strong correlation between men’s flourishing lives and their relationships with family, friends, and community. Those who kept warm relationships got to live longer and happier • The key to healthy aging is relationships, relationships.
3. Loneliness • Social isolation significantly increased a person’s risk of premature death from all causes, equal to smoking, obesity, and physical inactivity. • Social isolation - 50% percent increased risk of dementia. • Poor social relationships associated with a 29% increased risk of heart disease and a 32% increased risk of stroke. • Loneliness was associated with higher rates of depression, anxiety, and suicide. • Loneliness among heart failure patients was associated with a nearly 4 times increased risk of death, 68% increased risk of hospitalization, and 57% increased risk of emergency department visits. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System, Washington (DC): National Academies Press (US); 2020 Feb 27.
4. Quarterly emergency admissions Frome compared to the rest of Somerset 2013 - 2017 Frome emergency admissions Somerset emergency admissions 1. Abel, J. , Kingston H. , et al. , Reducing emergency hospital admissions: a population health complex intervention of an enhanced model of primary care and compassionate communities. Br J Gen Pract, 2018: p. bjgp 18 X 699437.
A new dimension • Whole population intervention – the changes that have taken place are across the whole population • Equally as valid to a teenager as to an elderly person • This is not solely a medical intervention – it is the union of new models of primary care with compassionate communities. • Use of IHI quality improvement methodology is key to change management
Same as hypertension! • Assess social relationships – equally as valid as measuring high blood pressure as a routine check • If a problem is identified, then seek a solution • Check to see whether the solution is working ie is patient taking the treatment • Follow up to see whether things have improved • Team and whole practice based change
3 levels of action on social relationships 1. Help people discover community resources – community connectors, groups, friendship cafes, health walks, choirs etc 2. Work with a health connector for one to one work, to find ways of developing goals and help people gain access to the wide variety of community 3. Help people discover, explore, enhance people’s personal networks.
4 key steps for primary care practices 1. Identifying those in need of support – whatever that means 2. Patient centred goal setting and care planning, including admissions avoidance and resuscitation discussion – development of hubs(including MDTs and admin support) inside the primary care teams to make this happen 3. Enhancement of naturally occurring networks 4. Linkage to community resource
Essential components / architecture of the model • Internal hubs inside the GP surgery • Community development service • Quality improvement methodology as the primary tool of change management.
7 key points – relationship based 1. Working relationships across teams and organisational silos, come first – face to face communication 2. Implement all the functions of the model 3. Ownership of change must be in primary care. Not top down 4. No criteria for identification other than clinical impression – do not use databases 5. Do what is best for the patient 6. Always use quality improvement methodology for change 7. Community development worker is part of the clinical team
What is most important • Improving patient care • Reintegration into our community. Reconnection care around the individual • Improving working lives • Reducing the moral distress of staff • Cost savings a by product but not motivation for the project
Problem solving Complicated • Recognition of the complicated nature of human beings and of the interplay between social, psychological and medical need • Recognising the power of human relationships • For patients • Within clinical teams
A Population based approach • Systematic • BASED IN AND PART OF PRIMARY CARE • Whole population not cohort (no inclusion or exclusion criteria) • Based on clinical assessment of need • Holistic
Why is QI so important • Builds system reliability • Engages and enthuses often disenfranchised health professionals • Puts the power of change into the hands of those who do the work • Ensures that a change is an improvement – otherwise don’t do it! • Deals with complex systems, process, outcomes and balancing measures • Lead GP in each practice
Understand what is working • Use quality improvement methodology to monitor and adjust hub model of working to stay on track • Start with the willing- small scale PDSA cycles to get a system working with those who are engaged and enabling • Then apply at scale once you have worked it out well • Allow whole team to be part of the design for their work and to own this
IHI Improvement methodology • Relies on ideas generated by the people who do the work, not top down • Leadership on the ground • Inclusive in nature • There are no bad ideas, only those that need testing in small scale testing cycles – adopt, adapt abandon • Listen to the sceptics – they have useful points • Use of run charts to demonstrate continuous improvement
Example of QI in clinical practice 3 options of compassionate community approach 1. Signposting to support on service directory 2. Enhancing naturally occurring networks of support 3. Referral to community promotor – what matters • • How many times did the conversation arise during clinic? How many referrals did you make to the community promotor? How many patients discussed at multidisciplinary meeting? What difference did it make to the patient – qualitative and quantitative?
“ In my GP surgery this morning, I had nothing to offer a significant proportion of the people I saw. People with lifelong depression, low selfesteem, agoraphobia and anxiety who have become socially isolated. An elderly man and a young mother, both feeling the effects of loneliness and lack of social support. A man in his 60 s who has recovered from a heart attack but is finding it hard to motivate himself to overhaul his lifestyle by stopping smoking and starting to exercise and eat healthily. A young man who has back pain for which no specific diagnosis or treatment can be found despite extensive investigations. An elderly, frail lady who is so scared of falling that she’s become a prisoner in her own home. ” Dr Ann Robinson Guardian -15 th November 2018
“ a community where people are supported to be creative, active and resourceful in response to their own and each other’s unique and shared needs, with easily accessible integrated care and support available to all ” Dr Helen Kingston Frome Medical Practice
Community Development Jenny Hartnoll
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