Practitioner Development
Programme
Skills Workshop 3
Welcome and Introductions
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Tutors
All in group
Name and area of work
House keeping;
-Manage self
-Toilets
- All teach all learn
-Fire alarm & exits
-Refreshments
-Mobile phones
Successes & Challenges
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Share your experiences from last workshop
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Skills, patients, systems
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Debrief
Aims Skills Workshop 3
During this workshop you will have the opportunity to explore the skills
which support you to;
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Support collaborative goal setting & action planning
Support the patient to review how things went
Share success
Consider what got in the way – barriers
Consider how to move forward – problem solve
Share your information & expertise
Explore how you will proactively follow up
Identify the support you need to progress
You will also have the opportunity to consider how your team and services
work and how these processes impact your ability to successfully support
patients to self manage and identify ideas you have to overcome barriers
Programme aim – review
Safe, effective, timely,
person centred, equitable
and efficient
The nature of the
interaction
created by the structures,
processes and
behaviours that exist within
the system
Achieving improvement
by changing relationships
between people & health services
Patients, clients groups,
service users, carers,
families and communities
Both the people who work in
and deliver care services and
the wider system
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The CCH Integrated Model
©The Health Foundation
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The Co-creating Health Integrated model
©The Health Foundation
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The CCH Integrated Skills Model
Exploration
E
Agenda
setting
Goal
setting &
Action
Planning
Planning
Goal
follow
- up
Problem
solving
©The Health Foundation
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Health behaviour modelling
Biological
Emotions / Thoughts
Social / Behavioural
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Skills list
•Reflection/Empathy
•Support autonomy & choice
•Explore agenda/priority
•Double-sided reflection
•Explore agenda: clarify
boundaries
•Explore ambivalence
•Invite goals
•Explore beliefs about selfmanagement
•Ask before advise
•Explore importance 0-10
•Problem solving
•Explore confidence 0-10
•Action planning
•Effective Follow-up
Inviting goals - review
Once you have explored importance and confidence support the patient
to consider an area that they wish to work on and help them set a goal
and action plan around this. This is the first step in supporting them to
translate intention into action. Remember to support their autonomy
and choice and be mindful of their level of activation.
You can take a long term view. Your patient is living with a LTC and
you have time to support small incremental progress which will build
confidence and skills.
• Is there an area that you would like to work on?
• How might you go about that?
• How important is it to you?
• How confident do you feel ?
Progress to an action plan
Once the goal has been identified you will need to support the patient to break this down
into small achievable steps which will be made up of the actions required to make progress
towards achievement of the goal. Do not assume that you know better than the patient
‘what is realistic for them’. Remember they need to build their confidence and problem
solving skills, share their success and have support to find ways to overcome their
challenges.
Goal setting, action planning and follow-up is a continuous loop of planned activity
resulting in continual development of the patients confidence and skills to self manage.
If we neglect any of these elements the cycle will break down.
The highest area of risk for this to happen is ‘follow-up’. Current service design and
resource constraints mitigate against effective follow and it is an historically weak area for
the NHS. We now know that Patients who receive follow up within two weeks of goal
setting and action planning make the best SM progress.
We must listen to our patients and together develop and embed successful ways to
provide and deliver meaningful follow-up within the constraints of today’s healthcare
economy.
Goal setting to action planning
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What is the goal that you are working towards?
What do you need to do to achieve the goal?
Which ‘bit’ would you like to work on
How important is it to you? (0-10)
What things might get in your way/ stop you doing it?
How might you overcome these?
When will you do it?
How often will you do it?
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If you visualise yourself doing this, how confident do you feel that you can
achieve this? (0-10). Explore using techniques from last workshop. What
makes it 6 rather than 5.....What would take it up to 7..............
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Patient’s are most likely to successfully undertake the action and
achieve their goal if their confidence is 7 or greater.
Making the plan robust
How often do we have an intention to do something and then it is never
quite the right time or there are too many obstacles? In order to make
the plan robust and give greatest potential for success we should
support patients to set SMART goals (really a SMART action plan) and utilise
the problem solving cycle skills that they develop in the parallel skills
programme.
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S
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Specific
Measurable
Achievable
Realistic
Time based
What you will do?
How much...how often?
How confident are you that you can do it?
How confident are you that you will do it?
When will you do it?
As you go through this process patients often revise their goal/action. Support
their autonomy to do this however you should both ensure that by the end of
the consultation that there is an agreed goal and plan that you will follow-up
The problem solving cycle
A key component of successful goal setting and action planning is to
consider the potential barriers and challenges that might ‘get in the
way’ and to identify and explore potential solutions to overcome these.
The problem solving cycle is a useful tool for achieving this and is one
of the skills that your patients will learn in the SMP.
Remember that we are supporting our patients to become more
confident problem solvers. We need to be their coach and support them
to find solutions that will work for them in the context of their lives.
We should resist the urge to suggest solutions and should provide
ample opportunity for the patient to identify these themselves.
Get lots of ideas
Evidence shows us that it is better to generate a range of possible
solutions rather than trying to find the ‘one perfect answer’.
Use your exploration skills to support the patient to generate a range
of possibilities. They should select one to try and then re-check
confidence
Ask the patient to reflect back to you what they are going to do.
In addition to confirming that you have a shared understanding
there is a value to the patient hearing themselves say what their goal is
and how they are going to achieve it.
Continue to address barriers until confidence is at least 7
If strategy they have selected is not effective support them to try
another of the ideas they generated
The unrealistic goal
The goal should belong to the patient. If confidence remains below 7
ensure that you have provided sufficient opportunity to explore barriers.
Other reasons for confidence being low may be that you have contributed
your own ideas to the goal and it is therefore not truly owned by the patient.
If appropriate recheck importance scale. This element may have been missed
earlier in the process.
If a patient has set what appears to be an unrealistic goal assess if there is any
‘risk’. If not support their autonomy and choice. If you consider that there is
some ‘risk’ use collaborative language to share your concerns and negotiate.
Do not make assumptions about what is ‘realistic for the individual or
judgements about their ability to achieve their plan.
Summary: Action plan
From goal agree the action plan (SMART)
Check confidence [7+]
If less than 7 re-examine barriers
Do not suggest goal unrealistic
Support patient’s autonomy & choice
Agree follow-up process
[Make sure the patient has selected to the goal and it is important to
them]
Interactive exercise
Goal setting and action planning exercise: can be done as one large
group or in small groups of 3 with a full group debrief of one example
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Consider a goal that you wish to achieve
Use the techniques discussed to explore the goal, set an action plan and agree follow
up
You should ensure you have a SMART goal
Debrief
Effective goal setting is an area that clinicians may find more
challenging as they often have less experience and fear that it may take
a significant amount of time
Efficiency comes with experience, however you may also need to
consider which role(s) within your team are best equipped to undertake goal
setting both with regard to skills and time. You may also wish to consider other
approaches such as group goal setting
Sharing knowledge & ideas
Within ‘the partnership’ there is knowledge and expertise on both sides.
You will have information, ideas and experience which may be beneficial for
the patient. It is appropriate to share these, however you should first give the
patient space and opportunity to explore their own thoughts and ideas and then
check that you have permission to share yours. This is respectful, sends a cue to
the patient and allows them to focus on the information you are giving.
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I have some ideas about that, would you like to hear them...
Other patients have told me what works for them, would it be helpful to share
them....
I have some information, would you like to see it.....
There is a support group, would you like me to give you the information about
it.....
Ask before advise –
is a powerful collaborative tool that can be used in any part of the consultation
Follow-up
Living with a long term condition is hard work.
Self management requires skills, knowledge and effort.
Patients need to feel supported, be able to share their success, have
support to overcome their challenges and have access to the appropriate
information and services.
This support comes from a variety of sources including; Health and
social care, family and friends, peer support groups.
This is a continuous process and we must ensure that our systems are
designed to successfully deliver this.
Follow-up is an core element of successful self management and
self management support, it is our responsibility to provide it.
Follow-up
• Follow up ideally within 14 days – especially important for people
at the beginning of their journey of activation
• Explore how patient got on.... How did it go?
• What went well?
• What was more challenging?
• Use positive language
• Do not add judgement or opinion with regard to challenges
• Use problem solving cycle to address barriers
Crucially progress to next goal/action plan to maintain momentum
– continuous loop
Examples
Simple and effective ways of building systems and processes for rapid
Follow up include:
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e-mails or texts can be typed up at the end of a consultation and set up to
send automatically a couple of weeks later
administrators as well as clinical staff can make follow-up phone calls, also
helping them feel more a part of the team
general practice can follow up on progress after a hospital appointment when
the patient sees the GP or practice nurse about their condition or some other
ailment.
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Models for follow-up;
Interactive exercise
Free think
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What systems do you have in place to provide follow up?
What follow up support do your patients want?
What works well?
What are the challenges/barriers?
What ideas do we have to overcome these?
How might we make these happen?
Examples of Activating interventions
•Access to health coaches
•Longer appointments
•Group goal setting and follow-up
•Text support between appointments
•Peer support networks
Experiential practice
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Consider the skills we have covered and decide what you would
like to try
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Most useful to select an area for which you attach high importance
and have low confidence
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Safe environment to try things in a different way and seeing what
happens
Action plan & next steps
The skill I am going to work on;
The patient focused activity I am going to work on;
The process I am going to work on;
Experiential practice
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Consider the skills we have covered and decide what you would
like to try
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Most useful to select an area for which you attach high importance
and have low confidence
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Safe environment to try things in a different way and seeing what
happens
Where do we go from here?
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Share SMP data
Share ideas for systems development
Agree team goal and action plan (SMART)
Identify continued support required: skills, patient activity,
systems
Action Learning Sets
Memory aids
Systems support tools