Title: Education and facilitation to improve clinical decisions and multidisciplinary team-working with older adults with multimorbidity
Funder: Department of Health and Social Care

Abstract: This project aims to improve the care of older people who have multiple long-term conditions and need to have their care coordinated across different services. As older people live longer, increasing numbers will need this type of care, but feedback from health and social care staff suggests care is often not joined up and people may not get the services they need. Staff say it can be difficult to provide good care because services are not coordinated and each person has a unique combination of conditions not covered by clinical guidelines. We will develop and trial an educational programme for teams of staff from family doctor practices and other community agencies: nurses, healthcare assistants, therapists, pharmacists, mental health workers and social workers. The education will provide knowledge updates and encourage staff to share their existing expertise using real-life case studies. We expect staff to need specific clinical skills, to be good at talking with and involving patients in their care, and to have team-working skills. We think staff already have many of these skills, but need time to review how to use them best when working with older patients who have multiple long-term conditions. Teams who take part in the education will also meet 3 or 4 times in their GP practice with a facilitator, to follow up ideas for making improvements to care. We expect improvements to be needed in how patients with the most complex needs are identified, how staff work together and with patients to plan care, and how they update each other about patients needs and the care provided. Staff and managers are keen to take this approach as it builds on professionals' existing expertise and avoids the pitfalls of structural or organisational change. We will trial this programme with 24 GP practices and the linked staff from services working with these practices, in Birmingham, Devon and Staffordshire. Patients and their carers at these practices will complete questionnaires before and after staff go through the programme. We expect to find that care improves, that patients are more satisfied with their care, and that they may not need to use health and social care services as often as before. We expect team-working to improve and staff to feel more satisfied with their role. Before the trial starts, in the Programme Development Grant, we will work with patients and staff to develop the programme so that it delivers the outcomes that everyone wants. This will involve analysing published research, interviewing staff and education experts, and discussing ideas with patient groups. We will use this information to develop the detail of the education and facilitation. This programme should benefit patients and the NHS by improving care and reducing costs.

Lay abstract: This project aims to improve the care of older people who have multiple long-term conditions and need to have their care coordinated across different services. As older people live longer, increasing numbers will need this type of care, but feedback from health and social care staff suggests care is often not joined up and people may not get the services they need. Staff say it can be difficult to provide good care because services are not coordinated and each person has a unique combination of conditions not covered by clinical guidelines. We will develop and trial an educational programme for teams of staff from family doctor practices and other community agencies: nurses, healthcare assistants, therapists, pharmacists, mental health workers and social workers. The education will provide knowledge updates and encourage staff to share their existing expertise using real-life case studies. We expect staff to need specific clinical skills, to be good at talking with and involving patients in their care, and to have team-working skills. We think staff already have many of these skills, but need time to review how to use them best when working with older patients who have multiple long-term conditions. Teams who take part in the education will also meet 3 or 4 times in their GP practice with a facilitator, to follow up ideas for making improvements to care. We expect improvements to be needed in how patients with the most complex needs are identified, how staff work together and with patients to plan care, and how they update each other about patients needs and the care provided. Staff and managers are keen to take this approach as it builds on professionals' existing expertise and avoids the pitfalls of structural or organisational change. We will trial this programme with 24 GP practices and the linked staff from services working with these practices, in Birmingham, Devon and Staffordshire. Patients and their carers at these practices will complete questionnaires before and after staff go through the programme. We expect to find that care improves, that patients are more satisfied with their care, and that they may not need to use health and social care services as often as before. We expect team-working to improve and staff to feel more satisfied with their role. Before the trial starts, in the Programme Development Grant, we will work with patients and staff to develop the programme so that it delivers the outcomes that everyone wants. This will involve analysing published research, interviewing staff and education experts, and discussing ideas with patient groups. We will use this information to develop the detail of the education and facilitation. This programme should benefit patients and the NHS by improving care and reducing costs.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE