Proposal title: Live Well Stay Well: A preventative primary care programme to better support self-care across Buckinghamshire
Partner organisation(s): 52 member practices across Buckinghamshire, Diabetes UK, HealthWatch, PPGs and ‘Wellbeing Champions’, Aylesbury Vale CCG, Buckinghamshire County Council, Healthy Minds – Oxford Health NHS Trust, and Parkwood Lifestyle Service and health coaches
Aylesbury Vale and Chiltern CCGs have identified ill health prevention and supported self-care as a high priority in their Primary Care Strategy: Live Well Stay Well.
The Patient Activation Measure (PAM) is seen as a useful adjunct for tailoring interventions, measuring outcomes and informing commissioning integrated interventions and ensuring more people have access to a wide range of evidence-based approaches that engage people in their own care.
The Single Point of Access will use the PAM to act as a discussion and tailoring tool for each person with an LTC and psychological and or lifestyle need when they are referred to the service. The PAM score will be used as an indication for signposting and/or referring individuals into the appropriate services to support behaviour change according their level of motivations. The aim is to use PAM as part of a person-centred assessment about which services are most appropriate and beneficial, rather than as an eligibility criterion for any particular service.
Proposal title: Extension of PAM usage in Barnsley
Partner organisation(s): South West Yorkshire Partnership Foundation Trust, DIAL Barnsley
Barnsley is committed to personalisation – with an extensive motivational interviewing training in place and the CCG is now commissioning a social prescribing service. It has been using PAM routinely with the care navigation service and is rolling out its usage in community nursing and primary care.
As an IPC demonstrator site, there is ongoing work with the most complex patients to understand how to best support them to live healthy lives. Initial work with their voluntary sector partner have found PAM as a key tool and highly effective in the care planning work (undertaken as part of the IPC work). A full evaluation to evidence and evaluate impact of interventions will be undertaken – this will include case studies, feedback about impact and comments on process and implementation considerations.
Barnsley will be working to develop capacity and awareness of concepts of ‘activation’ as an outcome of care planning within the community sector.
Proposal title: Brent Self Care – PAM as a Tailoring Tool and Outcome Measure for LTC case management
Partner organisation(s): Brent GP Network Collaborative, CVS Brent, strategic voluntary sector providers
Self-care is embedded within our Whole Systems Integrated Care (WSIC) model, providing care planning and case management for patients aged 18 with LTCs. Patient activation is one of three key self-care deliverables in Brent – the others are ‘Care Navigators’ (voluntary sector staff working within multidisciplinary teams) and ‘staff training’ (techniques such as Coaching for Health and Motivational Interviewing). These deliverables enhance our model of long-term condition management – risk stratification, anticipatory care planning, patient-led goal setting and multidisciplinary interventions.
With the support of GP practices & Network teams across Brent, patients will receive a PAM assessment, used to tailor care plans and goals. PAM will influence the way professionals work with patients, the scheduling of interventions (maximising available resource) and use of voluntary sector support and guidance.
Voluntary sector services will be mapped to PAM levels/scores and voluntary sector organisations engaged via the Brent Self-Care Steering Group. Brent CCG will also work closely with partners across North West London and are part of NWL-level Self Care and PAM Steering Groups to ensure learning and best practice on using PAM is shared at the regional level.
Proposal title: Use of Patient Activation Measure in Bristol
Partner organisation(s): Bristol City Council, Bristol Public Health, Bristol Ageing Better – Age UK Bristol and Bristol Community Health
Bristol, North Somerset and South Gloucestershire CCG footprint are working on a joint approach to develop clinical and care pathways to deliver change at scale and pace, with the pathways focussing on self-care as a major work stream of the STP.
Bristol will use PAM throughout the patient care pathway, from prevention interventions with public health, through to the local third sector, community providers and acute settings. They aim to use the tool to tailor the design of services and offer more support to individuals with lower PAM scores who are in need of secondary care, the area most in need of reducing activity. The tool would be used in a variety of work streams and patient cohorts, from those who are accessing preventative support and early-diagnosis, through to individuals on stroke, respiratory, heart failure pathways as well as patients with complex discharge pathways. PAM will be used to assist in the expansion of Personal Health Budgets including involvement in the Integrated Personal Commissioning pilot.
PAM will support the drive for patients to become actively involved in their care, increasing the chances of living as well as possible for as long as possible, by getting the right information and support at the right time.
Proposal title: Empowering patients within the Extensive Care Service
The Extensive Care Service (ECS) is part of the Fylde Coast Vanguard and has the capacity to accept 6,000 patient referrals per annum. Working closely with patients, the service aims to assist them to improve their health and well-being; support them to manage their own conditions and provide effective interventions when they are needed in order to better manage exacerbations of their conditions.
One of the key components of the ECS’ care model is patient activation. The care team’s understanding of an individual’s ability to contribute to the management of their own health and well-being is key to ensuring the success of this approach. The model is new, different and includes the development of a unique role – a ‘wellbeing support worker’ (WSW). These individuals will be a consistent feature in a model which enables a fuller understanding of a patient’s ‘activation’ ability so that engagement and support can be tailored appropriately.
As the patient achieves their goals, the service will put in plans for a safe discharge back to primary care. A final questionnaire is completed to ensure the patient’s level of activation has improved and they feel empowered to self-manage their conditions and show the progress the patient has made since being referred into the service. This will also form part of the evaluation of the effectiveness of the service and of the key roles within it. This information will be help to refine future iterations of the service and the New Models of Care programme.
More details about the use of PAM in Blackpool are available in this case study.
Proposal title: Ealing Self Care – PAM – A tailoring tool and outcome measure
Partner organisation(s): Central London Healthcare
As part of its Whole Systems Integrated Care plans (WSIC), Central London CCG are mobilising a Care Co-ordination Service (CCS). The CCS will support a new care planning specification intended to put care plans in place for 30% of the Practice population, to include; all those over the age of 18 with a long-term condition and everyone over 65. It will also include anyone whom clinicians believe would benefit from extra support. The care planning process will empower people to determine their own actions and goals, and places emphasis on prevention and proactive behaviours to enable the patient to maintain their a good quality of health and wellbeing for as long as possible. The CCG has articulated an ambition for the CCS to deliver PAM to all patients being care-planned as a tool for ascertaining patient confidence to self-care, to provide tailored interventions and to measure increasing patient activation.
By embedding PAM into the new care planning process, Central London CCG will improve engagement between providers and patients, enabling the behaviour changes that come with moving from a reactive to a proactive care service. It will also put a much greater emphasis on self-care and provide support to those who are not yet in a position to effectively manage their own care.
Proposal title: West Dorset holistic pathways for patients with long-term conditions – a collaborative patient-centred approach
Partner organisation(s): Dorset Healthcare University Foundation Trust (Dorset healthcare)
The introduction of the Patient Activation measure (PAM) will be a catalyst for clinicians and professionals from primary and secondary care to develop pathways to ensure that patients can access the necessary help and services designed to improve their health and empower them to move towards self-management of their long-term condition. This changing approach with the clinician working with the patient in a therapeutic conversation whilst completing the survey will shift the balance from a predominantly medical model toward a holistic approach in line with the ethos of person-centred care.
In Dorset, the end point of a number of existing care pathways remains with statutory providers in the health system and do not always result in the patient becoming re-established in the community. This project is intends to address this issue and is anticipated to increase the utilisation of ‘My Health My Way’, ‘Live Well Dorset’ and voluntary groups.
The project will commence with the pulmonary rehabilitation patients in Weymouth and Portland and Dorchester, where the PAM will be used as part of the initial assessment alongside the other evidenced measures and repeated on completion of the programme and at a 6 month review. This will enable the project team to review whether the rehabilitation programme of exercise and education itself enables a shift in patient activation levels and provides, at the end point of the programme, a score that will identify appropriate signposting or onward referral to maintain or improve the score further.
Whilst this part of the project is in progress, pathways for other long-term conditions will be developed and reviewed collaboratively embracing learning from the pulmonary rehabilitation project. Patients will then be enrolled in the programme and the outcomes monitored for 3 years.
Proposal title: Ealing Self Care – PAM as a Tailoring Tool and Outcome Measure for LTC case management
Partner organisation(s): London Borough of Ealing, Public Health Ealing, West London Mental Health NHS Trust, Ealing CVS
In Ealing, people with long-term conditions are the most frequent users of health care services accounting for 50% of all GP appointments and 70% of all inpatient bed days. PAM is a key enabler to support people diagnosed with long term conditions to develop the skills required to be able to effectively self-manage their care and take more control of their health and wellbeing.
Ealing plan to use PAM levels to tailor care planning and support to individual patients’ needs and to measure success. Their Homeward Service reduces hospital admissions through managing a wide range of patients in a sub-acute phase needing more support than the GPs and core community services can offer. As patients move along care pathways they can transition between Homeward and the Models of Care Scheme. This will provide an opportunity to carry out PAM assessments and to tailor care plans.
A range of training has been commissioned to support patients with long term conditions. PAM scores will identify those who would benefit most from the training so they can be referred quickly and the benefits can be evaluated through their PAM scores. Ealing will work in partnership with Primary Care to identify the most appropriate resources and key staff to train and agree the process for carrying out and reviewing PAM Assessments and using the levels to tailor care.
Proposal title: Using patient activation measures to support the design, implementation and evaluation of New Models of Care
Partner organisation(s): NHS Blackpool CCG, Blackpool Teaching Hospitals NHS Foundation Trust, and Fylde and Wyre Local Health Economy
The Fylde Coast Vanguard programme is focused on the implementation of two care models, Extensive Care and Enhanced Primary Care, to reduce demand on acute services, improve health, wellbeing and patient experience. It aims to deploy a proactive, systematic care-planning approach, tailored towards the needs of the individual to improve their quality of life and support people with complex health needs to live independently for as long as possible.
The programme seeks to ensure that the Care Teams’ understanding of an individual’s ability to contribute to the management of their own health and wellbeing is central to designing patient-centred care plans and goals. This includes the development of a unique non-clinical role of a ‘Health and Wellbeing Support Worker’. Use of the PAM tool will help to identify interventions appropriate for the individual, and assess whether activation increased for the patient cohort.
In addition, the use of PAM will allow the health and care economy to have an iterative approach to the design of future implementations of the agreed care models, adapting the staffing models and approach to patient engagement in accordance with the findings from the initial sites.
Proposal title: Embedding the Patient Activation Measure in Gloucestershire services to improve outcomes and support delivery of tailored personalised care
Partner organisation(s): Gloucestershire Care Services NHS Trust, District Councils, 2gether NHS Foundation Trust, Gloucestershire County Council and Gloucestershire Voluntary and Community Services Alliance
One of the key STP aims of Gloucestershire CCG is to embed the concept of patient activation in services to radically upgrade prevention and shift to more fully involving individuals in their own health. The Healthy Individuals Programme Group has been making good progress in developing their strategic approach to self-care.
Gloucestershire aim to use PAM in different services as an outcome measure and a tailoring tool giving healthcare professionals insight to more effectively support the individual according to their activation level.
A significant implementation site for PAM is within the ‘Place Based Commissioning Model’ covering 120,000 population clusters – a key transformational development within the Gloucestershire STP. In this setting, PAM will be integrated into a larger programme of work, supporting delivery of a truly person-centred care approach with the target population and test impact of activation on service usage in a ‘live’ environment.
Proposal title: Using PAM to embed individualised self-care strategy across the Hammersmith & Fulham population
Partner organisation(s): Hammersmith & Fulham GP Federation
There are 31 GP practices in Hammersmith & Fulham serving a population of 190,000, of which an estimated 40,000 residents have one or more long-term conditions. PAM will play a key role both in tailoring support for individuals to self-care, and in measuring success.
Hammersmith & Fulham CCG recognise self-care as an essential long term strategy both for disease management and health promotion and, as such, they are working with public health and voluntary sector providers which perform NHS health checks and accept referrals for smoking cessation, obesity, hypertension and diabetes; as well as people who are undiagnosed but at risk. PAM will help to identify which patients require more intensive support, and target the type of support required. PAM assessments will be undertaken by GPs as part of the referral process to the lifestyle interventions, and will be embedded into LTC annual reviews and diabetes clinics via out-of-hospital service contracts and GP network plans.
Proposal title: Use of PAM as a Tailoring Tool and Outcome Measure as part of Self-Care Planning
Partner organisation(s): Harrow Health CIC, Public Health, Harrow Council
Harrow CCG delivers a Whole Systems Integrated Care (WS) approach for the 253,859 population it serves. The primary objective of WS is to demonstrate the sustainability of a multi-disciplinary and collaborative approach to the provision of anticipatory care in the community to support patients at high risk of hospital admission, to prevent admission and to provide better care following discharge from hospital. PAM will be a key enabler for empowering patients to self-care and will be used as a tailoring tool for measuring and supporting self-care.
Through risk stratification, Harrow have identified 6,900 patients who will benefit from support through the WS programme. PAM will be undertaken for all patients within the WS cohort in order to encourage greater consideration of opportunities for self-care and to tailor the development of the Anticipatory Care Plan.
Harrow Council are consulting on a new information Advice and Advocacy Strategy which will make it easier for patients and health and social care professionals to identify the support available. In addition, the Harrow Pubic Health Team is looking at mechanisms to improve signposting to self-care services. The database of services will be mapped to PAM levels to ensure targeted support.
Proposal title: Use of Patient Activation Measures as an Integrated Personal Commissioning Demonstrator Site
Partner organisation(s): Stockton Borough Council, North Tees and Hartlepool Foundation Trust, Catalyst (VCSE sector) and Hartlepool and Stockton Health
The Integrated Personal Commissioning cohort in Stockton on Tees is working with people over the age of 65 with long term conditions, in particular, those with respiratory conditions with a focus on COPD. The CCG will use PAM to support both the individual and the IPC programme to measure the impact of IPC on their lives and their outcomes.
The CCG aims to use the PAM tool within primary care. Plans are being developed with the local GP Federation, Hartlepool and Stockton Healthcare to provide non-clinical care co-ordinators within GP practices to undertake holistic care planning for patients most at risk of a hospital admission or patients with long term conditions. Using PAM will support care co-ordinators to plan the best use of available resources for patients. Most activated patients could be connected to their GP using the Florence Healthcare App, for example, whereas the least activated patients could be offered more intensive face to face support within practice.
It is envisaged that using the PAM will improve the relationship between the patients and the clinicians/professionals and help to facilitate a ‘different conversation’.
The evidence from PAM will help to inform the IPC programme about commissioning and market development and to support the personal budgets process.
Proposal title: Applying predictive technology to identify LTC patients for support with self-management and early-interventions by clinicians
Partner organisation(s): Rochdale Council, Merck Sharp & Dohme Limited
This Long Term Conditions test bed site aims to reduce the incidence and progression of single and co-morbid LTCs in the population of Heywood, Middleton and Rochdale.
- Support to more patients (and people at risk of developing LTCs) in making informed choices to improve their health, and support them stay healthy for longer.
- Reduction of healthcare resource utilisation (unplanned hospital admissions and re-admisison within 28 days) for patients with LTCs
- Support to GPs and other healthcare professionals in gaining insight into the commitment and capability of their patients to self manage their lifelong conditions and to deliver personalised care.
Expected benefits include disease prevention, reduction in disease progression and associated complications, fewer emergency admissions, A&E attendances and outpatient appointments and shorter length of hospital stays.
The programme will map patient activation at regular intervals, and comparisons between two cohorts on levels of self-management and health improvement motivation will be made.
The progress and effectiveness of identifying appropriate interventions using PAM, will be a major component of the programme, which is being evaluated by University of Manchester. Results will be shared across Test Bed communities of practice and other partners across the NHS.
Proposal title: Hillingdon Integrated Person Centred Self-Management Outcomes Model
Partner organisation(s): The Hillingdon Hospitals, Hillingdon GPs, Central Northwest London Foundation Trust, Other Third Sector partners, Hillingdon CCG
H4All was an early adopter of PAM within the development of integrated services for older people (aged 65 years and over) with long-term conditions. Working with GP-led multi-disciplinary teams, the tool was employed within the third sector for preparatory work and screening of selected patients prior to care planning. The team using PAM has now been expanded, establishing a Wellbeing Team working alongside GPs, community teams and the acute trust.
The pilot established robust baselines against which to evaluate interventions; enabling appropriate tailoring of services and targeting resources for best outcomes. H4All also recognise the potential to improve patient stratification by including the PAM level as a risk indicator and to help manage risk sharing with the patient and health care professional.
Hillingdon’s Accountable Care Partnership (ACP) will further develop its use of PAM by: expanding and developing the tool with a wider population of older people and adults with a long term condition and by the introduction of ‘Carer PAM’.
Proposal title: Using PAM to tailor care and support planning in community and secondary care services
Partner organisation(s): Brighton and Sussex University Hospitals NHS Trust, Sussex Community Foundation NHS Trust and Surrey & Sussex Healthcare NHS Trust
Horsham and Mid Sussex CCG are part of the PAM learning set and have been using the measure since 2014 in their Tailored Health Coaching pilot.
The CCG aims to extend the use of PAM with the LTCs teams in the care planning process to engage patients differently, in a way that is timed and pitched at the right level to achieve an optimum intervention. This will help to review and implement locally commissioned services across the most prevalent long term conditions.
To shift the emphasis of care to include improved self-management, the CCG has agreed the use of a CQUIN with the main providers for 2016-17 to incentivise improved person centred care and use of PAM to tailor their approaches. The CQUIN includes training for staff on how to use motivational interviewing and coaching techniques to empower patients to develop improved knowledge, skills and confidence in self-management.
Proposal title: Integrated Health and Social Care – Developing a Multi-Disciplinary Tailored approach using PAM
Partner organisation(s): Hounslow and Richmond Community Healthcare Trust
Hounslow CCG aims to increase proactive self-care management of its population by utilising PAM to enable tailored care and support, including patient-led goal setting. Its approach enables wider primary care services to coordinate care and support for individuals with social, emotional or practical needs to the most appropriate fit in accordance to their PAM Level from the range of local, non-clinical services provided by the voluntary and community sector. To support this, Hounslow CCG has commissioned a Local Hounslow Services directory to include social prescribing interventions including support groups and walking clubs, to community cooking classes and one-to-one coaching.
This is an opportunity to co-develop the model of care at a GP Practice level utilising the variety of ready tools and enablers including PAM. This concept of co-design will bring together Hounslow’s primary team to develop workforce, drive efficiencies in workload and relieve demand, leverage benefits of technology, to have an outcome of support to local practices in redesigning the way modern primary care is offered to patients across Hounslow.
Proposal title: Developing a model for self-care for people with long term conditions within Cornwall
Partner organisation(s): Changing Lives Cornwall CIC, Health Promotion Service, Cornwall Council, SW Cardiovascular Clinical Network and St Austell Health Care
The CCG’s focus is on a personalised approach to delivery of health by tailoring support to individuals using motivational interviewing techniques, improving people’s ability to self-manage/care and based on the people’s activation levels. It views Integrated Personal Commissioning (IPC) as the overarching principle into which different cohorts can be linked.
Using PAM under IPC, practitioners can tailor their approach using guided conversations and adapt goal setting and support needed within the person’s care and support plan, utilising colleagues across the voluntary care sector to support individuals to reach their goals, including having a Personal Health Budget/Integrated Budget where appropriate.
Through using the PAM in a structured and focused way, NHS Kernow aim to increase the number of people with diabetes who attend a structured education course and also reduce the number of lower limb amputations in high risk diabetic patients.
The South West Cardiovascular Clinical Network is working with partners to improve clinical outcomes for people with a cardiovascular LTC and aim is to increase the patient activation levels to increase self-management in 750 people.
The CCG does not intend to commission additional interventions at this time, and aims to understand how the capacity and programmes currently available can be enhanced by the use of PAM to help people become activated to manage their own health.
Proposal title: Reducing Hospital Admissions: Determining effective support for people with LTCs to remain well at home
Partner organisation(s): Better Care Together Vanguard, Fylde and Wyre Local Health Economy, Fylde and Wyre CCG, NHS Blackpool CCG, Blackpool Teaching Hospital NHS Foundation Trust, University Hospitals Morecambe Bay NHS Foundation Trust, Cumbria Partnership NHS Foundation Trust, North West Ambulance Service NHS Trust (NWAS), NHS Lancashire North CCG, NHS Cumbria CCG, North Lancashire Medical Group, South Cumbria Primary Care Collaborative, NHS Greater Preston CCG, NHS Chorley & South Ribble CCG, Blackburn with Darwen unitary authority, NHS East Lancashire CCG and NHS West Lancashire CCG.
The Lancashire and Cumbria Innovation Alliance (LCIA) Test Bed will be delivered through two neighbouring Vanguard sites (Fylde Coast Local Health Economy and Morecambe Bay Health Community). Over the next two years, a combination of innovative technologies and practices aimed at supporting older people, people with long-term conditions (including dementia) to remain well in the community and avoiding unnecessary hospital admissions will be implemented and evaluated.
As a provider of Community and Mental Health Services across Lancashire, LCFT will use PAM to tailor their proposed Models of Care to suit the population. They will use the licenses in services to tailor and embed their Sustainability and Transformation Plans which includes self-care and prevention and whole person health and self-management, as their core health strategy. LCFT also aim to use PAM licences in its wider community services to offer Whole Person Health (physical and mental health management from a single clinical team) underpinned by supported self-management to create a person centred approach.
Proposal title: Enabling Health Coaching through the use of evidence based practice and data collection
Partner organisation(s): Leeds & York Partnership NHS Foundation Trust
Health coaching is seen as a key skill and mindset approach required by the clinicians across the Leeds transformation programme. Within the Integrated Care and Prevention Programme, health coaching has been identified as a key element for both the self-management work stream, targeted prevention and system change.
The Patient Activation Measure was introduced as a Better For Me (BFM) outcome measure in November 2015. The aim of BFM is to increase patient activation, therefore increasing self-management and decreasing reliance on health services. PAM is being utilised in the programme as both an outcome measure and a measure to inform intervention and treatment.
Progress is currently shared across the Leeds health coaching steering group partners which include health providers and public health. Data collection will enable to see progress on patient outcomes aligned to goal achievement as well as patient activation.
Proposal title: Luton’s joint approach to understanding and enhancing individual’s activation levels to support self-management
Partner organisation(s): Luton Borough Council, Cambridge Community Services NHS Trust, East London Foundation Trust, Healthwatch Luton, Patent Reference Group Luton and Live well Luton
The ‘Better Together’ Programme in Luton aims to bring together collective resource and action to support the population to stay well through large scale change among commissioners, providers and the residents towards choices and options that maintain and improve health and wellbeing. This includes a range of programmes such as Integrated Personal Commissioning, Social Prescription, Social Investment Bond for homelessness and housing, multi-disciplinary teams and long-term condition management to provide intensive support. All these projects aim to shift towards self-care and PAM will be used as a consistent measure to assess change and impact.
PAM will be used as a measure of a person’s knowledge, skills and confidence to enable better care planning/support by understanding each person’s starting point and tailoring support accordingly. The programme will embed the use of PAM as standard practice for cohorts where there is an established evidence base.
Cambridgeshire community services will use the PAM tool to support the self-management and engagement of patients from a range of cohorts including people with long-term conditions such as diabetes, COPD, heart failure and Parkinson’s disease. The Better Together programme will use PAM with a cohort of patients that can benefit from intensive case management in assisting individuals’ self-care, maintain health and minimise risk of hospital admission.
Proposal title: Newham Integrated Self-Care / Self-management Programme
Partner organisation(s): North-East London Local Pharmaceutical Committee (NELLPC), London Borough of Newham, East London Mental Health Foundation Trust, Active Newham and Healthy London Partnership
Newham has a high level of mortality before the age of 75 years, which reflects the health and health care challenges within the borough. In response, there has been a strategic drive towards developing self-care support within the context of integrated care.
The Newham Community Prescription (NCP) programme aims to increase physical activity and healthy behaviours of Newham residents identified as ‘at risk’ of diabetes and/or cardiovascular disease with a BMI >=30. Lifestyle advisors will use the PAM licenses with those ‘at risk’ as a means of ensuring patients are receiving the most appropriate types of support for their level of activation.
Newham’s Self-Management Support Programme (SMSP) is a health coaching and signposting service provided by Community Pharmacists, which will provide people with long term conditions (LTCs) with the skills and confidence to enable them to take a more proactive role in managing their own health. This intervention facilitates and supports people identified through Newham’s risk stratification model as being at moderate risk of hospital admission to develop a well-being plan.
Proposal title: Patient Activation – A system-wide approach to self-management
Partner organisation(s): GP Surgeries and Integrated Community Care Teams across the two CCGs
This joint proposal from two CCGs aims to extend the use of PAM and achieve a wider impact on the local health economy in Hampshire. Self-care is a key priority for both North Hampshire and West Hampshire CCGs to develop a self-care strategy for a stepped change over the next 3 years. The plan will be underpinned by principles for new care models and based on health and wellbeing approaches including social prescribing, health coaching, peer support, asset based community development and personal health budgets.
The desired outcomes include changes in patient behaviour, with patients making informed decisions and care based on principles of Self-Directed Support. This will be achieved by engaging patients at the right level according to their stage of activation; working through their personal journey from acceptance towards active involvement of self-management. Patient cohorts for year 1 include specific long-term conditions such as pain, diabetes and COPD.
It is envisaged that using PAM will help to deliver outcomes based care, eliminating waste of unnecessary services and approaches in risk stratification.
Northamptonshire Healthcare NHS Foundation Trust
Proposal title: Community Asset Based Approach for Persons with Long Term Conditions
Partner organisation(s): Northamptonshire Carers Association, Northampton GP Alliance/Doc Med, Voluntary Impact Northamptonshire
The Trust has been involved with the national Year of Care programme – evidence from this shows that the demand on services and resultant cost increases significantly amongst patients who are 50 years or over with three or more LTCs. It is believed that increasing self management skills and confidence within this cohort will have the greatest impact on reducing use of reactive services.
The Trust is one of six areas to participate in the spread test phase for the Health Foundation funded Community Asset Based Respiratory Clinics which was successfully piloted in Coventry in 2015.
In year one, the PAM focus will be on patients with COPD. The tool will be used to establish patient confidence in self management prior to accessing the asset based clinics and after 12 and 24 weeks of engagement. The ‘clinics’ are based on a model of social and peer support but have access to health and carer experts in an informal setting and direct access for those who would benefit from it to psychological therapies. Sessions are co-designed by patients and project staff (employed by Northamptonshire Carers).
The project will initially target over 2000 people in Northampton West and Daventry localities to understand factors that affect patient activation between rural and urban areas. The learning from this initial phase will inform the spread of the model across Northamptonshire to reach all existing COPD patients and those newly diagnosed during the year. In years two and three, the programme will be expanded to address additional LTCs.
Proposal title: Supporting greater personalisation and self-care across health and social care in North Somerset
Partner organisation(s): North Somerset Community Partnership, North Somerset Council, Avon and Wiltshire Mental Health Partnership Trust, 1 in 4 People Ltd, Compass Disability, Enham Trust, North Somerset CCG/Sunnyside Surgery Patient Participation and Involvement (PPI) Group and Solo Support Services
North Somerset CCG is leading a multi-agency approach to developing greater personalisation of health and social care in North Somerset and sees the Patient Activation Measure (PAM) as essential in supporting this aim. The CCG and its partners are closely involved in the South West Integrated Personalised Commissioning Programme and the Moving Forward with Personal Health Budgets programme to use budgets more creatively to improve outcomes for patients and service users.
In 2016-17, PAM will be used with the POET tool in the development of new PHBs/IPCBs and as part of the evaluation process for the existing ones. PAM will be used in the diabetes structured education programme and to support a local pilot initiative aimed at patients learning together how to self-manage and improve their own outcomes using personal data and medical record access.
As part of the CCG’s self-care programme, PAM will be used to ensure that the correct approach can be developed to support individuals and maximise the benefits of self-care.
Proposal title: PAM implementation in the Trust’s integrated teams
Partner organisation(s) – Central Manchester Foundation Trust and Buzz (Manchester Health and Wellbeing Service within Manchester Mental Health and Social Care Trust)
Manchester has some of the poorest levels of ill health, morbidity and early mortality rates in England. Focussing on prevention and addressing the underlying causes of health is a key priority. The Trust is working in partnership with Central and South Manchester, other providers and 3 CCGs to deliver the citywide strategic programme ‘Living Longer Living Better’ (LLLB), which will develop and lead the framework for integrated care and service transformation to address the growing levels of ill health.
The Trust is part of the Manchester Citywide Self Care Reference Group, who have developed a Self-care strategy under the umbrella of LLLB. The target cohort includes people with long-term mental or physical conditions. The strategy commends the PAM tool and supports PAHT evaluation that PAM is a catalyst to improve self-care with people and enabling self-care with practitioners.
PAHT aims to utilise the PAM in conjunction with a robust patient centred training programme, to tailor support to individual’s activation levels. This will recognise that individuals possess differing levels of knowledge, health literacy, skill and confidence to manage their health. This programme will be on scale for the integrated teams.
Proposal title: Using PAM as a tool to enable the self-management culture across the PCFT footprint
The Trust is working closely with the Greater Manchester Devolution Team to develop the collective plans to deliver the strategic transformation priority of ‘radical upgrade in population health’. It has a key strategic objective to embed self-care and self-management practice in every service it provides.
The Trust is a member of NHS England’s Commissioning for Person-Centred Care Working Group. It has been developing innovative training programmes to support self-management and person-centred care, and a Self-Management Toolkit that facilitates staff and service development. In 2015, the Trust piloted a whole-systems approach to supporting self-management.
As part of its Patient Activation delivery programme, the Trust will initially use PAM internally, and later work in partnership with the local authority, CCGs and social care providers across patient pathways in several boroughs. It has been using PAM in pulmonary rehabilitation and integrated neighbourhood teams settings, and believe that PAM can challenge existing pathways and “pull” on self-management approaches that build increased activation. It aims to use the measure in both physical and mental health long-term conditions and in supporting integrated, whole-person care approaches. It will use the PAM primarily as an enabler to staff/patient culture change, and as a patient outcome measure. It aims to identify pockets of excellence and areas with particular challenges in order to ensure appropriate support is tailored to meet the variety of needs emanating from the range of clinical services offered.
Proposal title: Supporting IPC through PAM (Public Health and Wellbeing Initiative)
Partner organisation(s): NHS Portsmouth CCG, NHS Solent, AGE UK Portsmouth, NHS CSW CSU
The Integrated Personal Commissioning (IPC) Project demonstrator site at Portsmouth is founded on a collaborative alliance of partner organisations. During the three years of the project, Portsmouth will work with four principal groups to see whether the IPC methodology of highly person centred care and support planning coupled with, where appropriate, the provision of a Personal Budget facility, has an impact on the lived experience of those individuals in terms of their sustained health and wellbeing. These four groups include older people with long term medical conditions, adults with a learning disability, children with special educational needs/disabilities and adults with mental health problems.
Portsmouth will use their public health and wellbeing teams to conduct the PAM surveys as these teams are most likely to reach individuals in the population where health activation is poorest, and provide targeted support for these individuals to have the greatest impact. Examples include Portsmouth Living Well Programme, where Age UK Portsmouth lead on delivering PAM primarily with older people with LTCs; and the Puffell initiative which aims to produce a locally embedded smartphone app to help people monitor things like smoking, alcohol consumption and exercise.
These programmes link tangentially to the IPC project demonstrator. It is believed that successful interventions with individuals (targeted by PAM surveys) will inform and support care and support planning to make it work better for individuals. It also ties in with a key intention on the Portsmouth Blueprint document, which is a joining up of prevention and wellbeing services. It is aimed that PAM scores and the targeted work will increase activation levels and enable individuals to self-care more effectively in Portsmouth.
Proposal title: Activating Sheffield: Shaping the City to be Person-centred
Partner organisation(s): Age UK Sheffield; Primary Care Sheffield; Sheffield City Council; Sheffield Health & Social Care NHS Foundation Trust; Sheffield Teaching Hospitals NHS Foundation Trust
Sheffield CCG is in its third year of working with NHS England to implement and evaluate the use of the PAM as part of its approach to managing long-term conditions and promoting self-care across the city. As part of their commitment to person centred care, they have developed a Locally Commissioned Scheme (LCS) with 69 GP practices in the city which incentivises the development of capability and capacity in delivering person centred care, so that the care planning process includes patient views, concerns and goals, social needs and shared decision making.
The CCG has established a Locality Support Team (LST) working citywide across localities developing practice capability and sharing good practice supporting culture change towards a way of working which recognises the patient as a partner in their own care. The LST are provided with skills in using the PAM, coaching, motivational interviewing managing groups, and technical support skills. Quarterly development meetings are held where information and learning is shared.
Practices are asked to give at least 80% of the patients who have a care planning appointment the opportunity to complete a patient survey. A robust feedback mechanism has been established with the Citizens reference group.
The CCG aims to continue working with national bodies including the Health Foundation, and RCGP, to promote Sheffield as a beacon site. As a pilot PAM site, it has resources of research, training and support tools, and their learning will be fed into national intelligence.
Proposal title: Solihull Together for Better Lives – Giving people greater control of their own health and wellbeing
Partner organisation(s): Solihull Metropolitan Borough Council, SoliHealth, The Carers Trust – Solihull Carers Centre and Experts by Experience
As an Urgent and Emergency Care Vanguard, the programme has a focus on self-care and person-centred care to transform the Solihull system. One of their service offers includes the Community Wellbeing Service, where people will be empowered to look after themselves when they can, and access care when they need to, giving them greater control of their own health and encouraging behaviours that help prevent ill health in the long-term.
Understanding individual and population activation levels is key for the CCG to deliver the system transformation necessary to provide services to support people according to their needs. PAM will be used to intervene to improve patient engagement and outcomes, population segmentation and risk stratification to target interventions, and to measure performance and evaluate the effectiveness of interventions to involve patients.
The use of PAM will focus on the Integrated Community Teams established as part of the Integrated Primary and Community Care Service. Care navigators will be embedded in every team to support patient activation.
Proposal title: Activated and engaged patients, and professionals delivering person-centred care
Partner organisation(s): South Somerset Vanguard (Symphony), Taunton Symphony Project, Somerset GP practices involved in the Somerset Practice Quality Scheme (SPQS), Taunton and Somerset NHS Foundation Trust, Yeovil District Hospital NHS Foundation Trust and Somerset Partnership NHS Foundation Trust
PAM sits at the centre of Somerset’s strategic vision of public services empowering people and communities to manage their own health and wellbeing. Over the last two years, as part of NHS England’s PAM Learning Set, the Patient Activation Measure has been positioned as a helpful tool in conversations between clinicians and patients, with Somerset’s strategic intention to socialise the use of the word ‘activation’ and the tool itself.
A wide range of systemic changes are in place to create conditions in which the power of ‘activation’ can be realised. This includes a rolling training programme for GPs, nurses, health care professionals and third and voluntary sector practitioners in person-centred care, person-centred care planning to influence their attitudes and beliefs towards activation and providing more in depth training in health coaching.
A number of ‘test and learn’ schemes piloting new coordinated person-centred models of care, such as South Vanguard and Taunton Symphony are incorporating the use of the PAM including in the personal care planning process. Health coaching is part of this approach and in South Somerset, staff specifically recruited as health coaches are employed. Three ‘test and learn’ schemes, Health Connections Mendip, the Village Agent Scheme in North Sedgemoor and the West Somerset Living Better Scheme, with a strong social prescribing element and using PAM are being trialled. As part of the strategic system change, the ‘Somerset Together’ Programme is using patient activation as a core metric to commission and monitor services.
Proposal title: Building self-care support into a healthy new town
South Eastern Hampshire CCG and East Hampshire District Council have worked with a number of partners to successfully achieve Healthy New Town status. A new town for Whitehill and Bordon is being designed which has health and well-being at its heart – this is also a key component of the East Hampshire ‘early adopter’ within the Southern Hampshire Multi-speciality Community Provider (MCP) Vanguard. ‘Better Local Care’.
The MCP Vanguard is exploring how those people with long-term conditions receive the support they need to manage their condition. A surgery in Whitehill and Bordon has been working with acute care specialists to identify patients with Chronic Obstructive Pulmonary Disease (COPD) and deliver appropriate care in their own GP surgery. The project ‘MISSION’ (Modern Innovative SolutionS in Improving Outcomes iN COPD) identifies local patients with a history of breathlessness, recurrent chest infections and offers them a full day of specialist assessment, education and self-management skills all at their GP surgery. This approach is being extended to those with diabetes.
The project will embed the Patient Activation Measure in this model of care to ensure that those caring for a patient understand their activation level and use this to support them in a way that is appropriate to their skills, knowledge and confidence. It will also help to provide an understanding of activation levels across the community – this insight will help to risk stratify the population to determine the interventions required in the local area to support individuals and the community and build this into the infrastructure of the Healthy New Town.
Proposal title: Activating activation in Hampshire
Partner organisation(s): South Eastern Hampshire and Fareham & Gosport CCGs, Health Education England across the South, Hampshire County Council, Royal Society for Public Health and Healthwatch
SHFT is part of the ‘Better Local Care’ and ‘North East Hampshire and Farnham’ Vanguards who are developing their work with primary care locally to adopt a system-wide approach to person-centred approaches to wellbeing, prevention supported self-care and support planning. The local system aims to support the higher levels of workforce development and it is considered that developing the knowledge of activation is essential for the system
The pilot will start within the Multi-specialty Provider Vanguard teams due to the complex population health needs and receptive CCG, primary care and community environment. Primary care will work to enable tailored interventions to patients for both prevention and supported self-care. The CCG will be asked to consider the use of system incentives to prioritise the changes.
Activation will be introduced in each of the practice teams, along specific long-term condition patient pathways with improved supported self-care offerings. It will also be used to support primary care re-design to effectively stratify groups of service users to highlight those ready to self-care and release GP time to support health inequalities in the area.
Activation will also be used within community and social care integrated reablement teams to understand the impact on rehabilitation and the maintenance/restoration of independence, along with supporting tailored interventions to maximise recovery and minimise downstream care needs.
Proposal title: Embedding Patient Activation measurement into tailored self-care initiatives with a focus on the diabetes pathway, MSK and alcohol harm reduction
Partner organisation(s): South Gloucestershire Council, STP footprint commissioners, Health Education South West, Sirona Care & Health, Developing Health & Independence Charity, Acute care and primary care providers
South Gloucestershire CCG and the local authority aim to nurture an environment where health and care professionals shift from being providers of information to helping patients acquire self-management skills. The CCG will use the Patient Activation Measure to aid in this quest and help answer the oft missed question “what matters to you, not what’s the matter with you?”
One of the three workstreams for the STP is ‘Prevention, Early Intervention and Self-care’, and PAM is a key priority for the local area with ‘Self-care at scale’ as a key element. The ambition is to identify the patient activation of the individuals and tailor support to all the patient contacts. Working towards this cultural change, the organisations will use PAM to identify the level of support necessary across the diabetes pathway interventions, musculoskeletal services and for individuals drinking alcohol at harmful and hazardous levels, recognising that the patients may have other associated long-term conditions.
Proposal title: A Better U – Developing people’s skills, knowledge and confidence to improve outcomes through self-care
Partner organisation(s): South Tyneside Foundation Trust, South Tyneside Council, Carers Association South Tyneside, First Contact Clinical, GP Practice, Women’s Health in South Tyneside, Blissability and Escape Interventions
From being the original pioneer self-care/self-management site, South Tyneside rebranded to ‘A Better U’ programme to develop peoples’ knowledge, skills and confidence to manage their conditions through changing interactions between care givers and care receivers, moving conversations from what support is available to what support can be given to help the person help themselves.
A potential gap was identified in the current pathway for COPD patients in terms of support offered upon diagnosis, prior to an exacerbation which results in hospital admission. The CCG will use PAM to actively engage with patients across the community to better understand the activation levels at a community and individual level to personalise responses and resources needed to engage with patients and carers. This will increase the likelihood of actively engaging patients so that they can control of the management of their conditions at every opportunity, improving their outcomes.
The tool will be utilised as a standard tool across the South Tyneside Partnership including 3rd sector and voluntary organisations, GP Practices and the Integrated Health and Social Care Community Teams.
Proposal title: Embedding self-care and person-centred coordinated care in South East London through local care networks
Partner organisation(s): Southwark and Lambeth Citizens Board, North Lambeth Practices Ltd, SW Lambeth Healthcare, South East Lambeth Health Partnership, Improving Health, Quay Health Solutions, Kings College Hospital NHS Foundation Trust, Guys and St Thomas’ NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, London Borough of Southwark, London Borough of Lambeth, Southwark CCG and Lambeth CCG
The CCG submitted the application on behalf of Lambeth and Southwark CCGs and their Local Strategic Partnership. South East London is a national Sustainability Transformation Plan (STP) exemplar site.
The CCG believes that of the nearly 4,000 deaths in Southwark in 2012-2014, approximately 30% were from causes considered avoidable, linked to the presence of underlying long-term conditions, and could be prevented through better self-management and improved activation. Measurement, understanding, acting upon and improving people’s activation measures is a central component of a new approach to care coordination for people with complex needs.
PAM will be used for baseline outcome measurement to understand needs, assess impact of interventions and guide further improvements. It will also be used to tailor support to individuals. Staff will be supported to value and interpret a person’s activation score, with tools and self-management support to mobilise collaborative and less medical model mind-sets. Implementation will be done initially through pilots, subsequently building towards the whole population with 3 or more long-term conditions.
Proposal title: A systems approach to self-care
Partner organisation(s): Tameside and Glossop CCG and Tameside Metropolitan Borough Council
The Care Together Programme in the area has a key element of developing a new model of care with emphasis on integration, promoting self-care approaches and early intervention and prevention. Tameside and Glossop aim to ensure that self-care becomes a system default, not a set of interventions delivered to patients, with a fundamental shift in the relationship between people and their health and between people and health and care services.
The measurement of patient activation will be a key tool in delivering this. The PAM will be used as a risk stratification tool, as an individual tailoring tool, as an outcome metric for their newly developed outcomes framework for the Integrated Care Organisation, and as a mechanism to tackle wider determinants that affect people’s health and wellbeing.
Proposal title: Improving person-centred care in Tower Hamlets by tailoring care and support according to people’s levels of activation
Partner organisation(s): Barts Health NHS Trust, East London Foundation Trust, Tower Hamlets GP Care Group and London Borough of Tower Hamlets
Tower Hamlets has some of the largest health inequalities in the UK with a diverse, young, mobile and fast growing population. Local research has shown that it has a high proportion of people with highly fatalistic beliefs that leads them to focus on the present. They have low levels of confidence about the relevance and efficacy of action to improve their health and reduce the risk of disease.
As an Integrated Care Pioneer site, MCP Vanguard and Integrated Personal Commissioning (IPC) demonstrator site, Tower Hamlets is aiming to improve health and wellbeing outcomes for people and reduce unplanned use of services through supporting people to change their behaviours and improving their ability to self-manage and make informed decisions.
Tower Hamlets has been part of the NHS England PAM Learning Set since 2014, and have used the PAM in small scale self-management pilots delivered via voluntary sector organisations. Following this, they commissioned their first self-management service which uses PAM to tailor the self-management support people receive.
Going forward, Tower Hamlets will use PAM to tailor the information and support individuals need to take an active role in the person-centred care planning process. It will use PAM to understand “where the individual is at” to help inform the conversations they have with health care professionals and support people to develop their goals and outcomes. The PAM score will be used to tailor the service offered to people, including self-management support, facilitating access to wider “more than medicine” services in the community through social prescribing and directing people to preventative service through locality based wellbeing hubs. Longer term commissioning plans and market development will be informed through a better understanding of the level of activation of the population and the services people choose when given greater control.
Proposal title: Use of PAM as a tailoring tool and outcome measure as part of self-care planning
Integrated Care Hub
Partner organisation(s): Age UK Kensington & Chelsea, Central London Community Healthcare, Kensington & Chelsea Social Council and London Medical Associates Ltd
West London are delivering a whole systems approach to supporting patients aged 65 and over through the development of two hubs serving the north and south of the borough. A phased approach aims to support 18,800 patients to be seen by multi-disciplinary teams, developing patient owned care plans to help support patients to support themselves. Patient activation is a fundamental part of this support and the roll out of the PAM tool will be initially based on this phased roll out.
In May 2016, West London commenced using PAM through their team of 35 Health and Social Care Assistants (HSCAs) and Case Managers (CMs). The entire approach to the patient is tailored to their PAM score, with consultation styles, care planning approaches, goal setting and self-care programme referrals based on the patients’ activation level. Third sector self-care services in West London have been assigned to PAM levels to indicate which patients will benefit most from each service and referrals to these services will be made based on the patients’ PAM scores. Self-care service providers will be educated around the use of PAM and will receive referrals with the PAM score, so they can tailor their service accordingly.
West London CCG are working with partners across North West London and are part of a PAM Steering Group to share learning across the patch. The group have agreed to a consistent approach to the evaluation of PAM at a local level which will support the national evaluation.
More details about the use of PAM in West London are available in this case study.
Proposal title: Patient Involvement in Managing Self (PIMS)
Partner organisation(s): Herefordshire CCG, South Worcestershire CCG, Redditch and Bromsgrove CCG, Wyre Forest CCG
The Patient Involvement in Managing Self (PIMS) project will encompass the work undertaken through the Patient Self-Management programme (PSM), the newly diagnosed or pre-diabetic patients within the National Diabetes Prevention Programme (NDPP) and Self-management of Diabetes through improvements in diet. The Patient Activation Measure will be used by the partner organisations to work together and assess their patient populations on a consistent basis, and apply the lessons learnt across the Herefordshire and Worcestershire Sustainability and Transformation Plan (STP).
Based on reported learning from PAM, interventions will be scaled up and over time, the measure will be used with a wider group of LTCs including COPD, asthma and heart failure. Areas already geared up to take on small developmental application of the PAM to support this longer term use include pharmacist led chronic pain management, improving outcomes for patients with epilepsy in collaboration with acute partners, using PAM within the volunteer and health champion arena and for addressing inequalities in CVD with local authority partners.
It is expected that this will enable clinicians to involve patients in co-producing their own treatment and care planning, leading to greater compliance, improved outcomes, and reduced unplanned care and emergency admissions.