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Leading for Outcomes – a Framework for Holistic Care |
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Mark Jones, Chief Advisor Nursing and Richard McLachlan, Senior AnalysClinical Services Directorate, Ministry of Health
By and large, nurses have based their practice on principles which acknowledge the importance of considering the needs of a recipient of their care in the context of their place in society. The so-called ‘social determinants of health' extend to cover not only the situation of an individual as single citizen, but to their situation in a family and community, and so far as the effects of employment and environment might have on health and well-being. Maori philosophy in particular reminds us of the significance of Whanau and the relationship between mind, body, and spirit in the maintenance of a healthy disposition. Much of this is encapsulated in the notion of ‘holistic' nursing care. We might ask, though, whether the traditional approach to health care in our country has really reflected these principles, and whether the challenges facing us are best addressed by a reinvigorated consideration of holism. Without doubt New Zealand is in the grip of an epidemic of chronic illness, which can more accurately be described as a burden of long term conditions for a large proportion of our community. To make matters worse, this burden is markedly increased for Maori and Pacific Island populations, particularly with respect to diabetes and cardiovascular disease. So, how do we move from a situation in which we seem to be ever pressured to expand our capacity to treat disease and sickness through demand for ever more acute care treatment facilities when waiting lists seem ever longer? In 2000 we made a significant decision to radically re-direct our health care intent. The New Zealand Health and Disability Strategy (MoH, 2000) laid bare the challenge really facing our health care system. The Strategy identified a situation in which our acute care (hospital) based services were stretched beyond capacity, and even with our points-based access management system, waiting times were precariously balancing the need for urgent treatment against the ability for the system to provide it. Against this backdrop this Strategy described the burden of chronic illness, with long-term conditions such as type-2 diabetes and cardiovascular disease taking a particular toll, with the accompanying inequity described above. Building on this wider template for the nation's health, we went on to identify the essential need to re-focus health care priorities to stop, or at least minimise, the risk from these conditions - through health promotion, proven interventions, and provision of care management strategies intended to help people improve their lives when coping with long term conditions. This approach to prevention and management is contained within the Primary Health Care Strategy of 2001 (MoH, 2001). The strategy seeks to change our culture of care provision to one which continues to maintain a quality service for those who are ill and in need of acute care but focuses resources at assisting people to make the best choices for their health and the provision of evidence based interventions which can be easily accessed in a partnership process with health professionals. Support for self-management is central to achieving effective partnership. Structural changes have been put in place to try and facilitate this. For example, Primary Health Organisations (PHOs) are now established throughout the country with around 95% of the population enrolled. PHOs have a mandate in partnership with District Health Boards (DHBs) to develop and support primary health care services specifically designed to deliver the Primary Health Care Strategy . Alongside these organisational developments we can find a new approach to considering the health and wellbeing of people in a truly holistic context, as individuals, family members, and as a part of wider society. This approach is embodied in the ‘Leading for Outcomes' framework. Leading for Outcomes has its origins in the State Services Commission's ‘Managing for Outcomes' (http://www.ssc.govt.nz/display/document.asp?NavID=253), a project intended to achieve a more responsive public service through evidence to strengthen decision making, better communication and improved interactions with stakeholders, and greater transparency and clearer accountability to Parliament and the public. These were excellent principles on which to build a framework for health care delivery which puts individuals at its centre, with professionals available as expert sources of information and evidence based interventions, to be drawn upon as part of a negotiated package of care. The ‘patient' no longer has things ‘done to' them; rather they become the focus of a comprehensive framework that considers their needs as a member of a community and wider society. A broad holistic view is pivotal to Leading for Outcomes, which provides a framework for all who are involved in the health system, whether in actual healthcare delivery, administration, or policy, to maintain focus on the overall results of our collective actions. The term ‘outcome' does not just refer to the immediate results of an action – the results for an individual of an intervention such as surgery or prescription for acute illness. Rather, the term here has a much broader application. Outcomes may be for a whole population (for example, increased life expectancy of Maori and Pacific Island men). A wide range of people will carry out the activities that lead to such a high-level outcome over a number of years. High-level societal (and therefore longer term) outcomes are the focus of not only individual or collective actions but also the way our institutions are developed, how they relate with one another, and how activities are funded. The Ministry of Health pursues four such high-level outcomes (see diagram 1 below). They are ‘Better Health', ‘Reduced Inequalities', ‘Increased Participation and Independence for People with Disabilities', and ‘Trust and Security' (in the provision of health and disability services). If we are to have any hope of achieving or improving these outcomes, we must seek ways to address the determinants of health and wellness and, conversely, illness and disease – over time and across populations. This calls for an explicitly cross-sectoral, intra-governmental approach – acknowledging and seeking to influence the effect of decisions made outside the health and disability sector on outcomes within the sector. Within health and disability, it is important that we describe the actions necessary to achieve such apparently general outcomes as improved health and reduced inequalities. The argument pursued through Leading for Outcomes is that if the incidence and impact of common long-term conditions are reduced among groups at greatest risk, it will be possible to reduce inequalities. The capability developed to improve outcomes for groups at greatest risk, will benefit the entire population.
1. A hierarchy of outcomes leading to better health and reduced inequalities
Because of the disproportionate extent of their impact, the current focus is on diabetes and cardiovascular disease. As specifically identified in the Primary Health Care Strategy , these conditions are causing increasing suffering and put demands on the resources and capabilities of our health system. It is becoming increasingly clear that this systematic outcomes-focused approach will work well for a range of long-term conditions. A second component of the Leading for Outcomes framework, the ‘Continuum of Wellbeing and Disease' model described below, identifies the different stages of risk, asymptomatic or manifest as disease, which can be affected by both public health and clinical interventions. This continuum of possibilities can be correlated with the outcomes hierarchy as it describes opportunities for evidence-based intervention that will take us along the path to improving outcomes. That is, as we seek to provide helpful interventions during the life course of any one person or group of people with a similar level of risk or ill-health, through reference to the hierarchy we can see how the health system must configure itself to facilitate delivery of the most appropriate intervention. The needs of these people or groups change with time and the extent to which they are predisposed to disease or illness and the extent to which they have initiated health enhancing behaviours with the support of health care providers in the context of holistic primary health care. Taking cardiovascular disease and type-2 diabetes as prominent examples of chronic conditions, the continuum describes their ‘life course' by dividing it into stages. Beginning with the healthy population, interventions become more intense and focused as the risk of morbidity and mortality increases - but always with an eye to the health determinants and opportunities for preventive activities.
2. The continuum of wellness and disease
Each stage is an opportunity for intervention. If focused on those in greatest need, and with progress systematically monitored, they should lead to a reduction in the unequal outcomes present in the system. Some examples from along the continuum:
Ability and willingness to access health and disability services is a key determinant of success in reducing outcome inequalities. The continuum of wellness and disease and the outcomes hierarchy respectively comprise the means and the pathway for improving outcomes. The third essential component of Leading for Outcomes is a way of monitoring progress through the different outcome levels. This is achieved through the performance management framework. The changes that need to happen in primary health care to make all this possible are a move to a population health approach, a move away from unconnected episodes of care to provision of continuity, support for patient self-management, and a greater level of community engagement. This latter point is especially relevant to the prevention and better management of long-term conditions. So much for the theory, what does this mean for nursing? As with other health professionals, the Leading for Outcomes framework allows nurses to do two things. Firstly it provides a tool to help match specific interventions and health care strategies with the specific need of the individual or family/whanau expecting their help at any particular moment in time. Secondly, it allows nurses to locate themselves from a point of view of their specific position, role and function in our system, with respect to the continuum of wellbeing and disease of their particular patient, client, or whatever. The nurse working in general practice can use the framework in partnership with medical colleagues to consider the profile of the population being served. How many people on the practice list are there with risk factors associated with a certain condition – diabetes or CVD for example? What is their demographic profile and where are they on the continuum? Are there some groups with a higher level or risk who should be reached first? Can effective interventions be put in place with them to halt or reverse their progression toward serious illness, or are they at a point where effective management of a long term condition and amelioration of its worst effects are the best place to concentrate effort? The hospital based nurse may well be caring for someone with an acute exacerbation of a problem arising from a condition which was potentially preventable. However, consideration of that patient's place on the continuum leads to the conclusion the most effective intervention is to be gained by stabilising and dealing with the acute episode. However there is still the opportunity to impart health-enhancing messages. The patient can be provided with a management strategy, in partnership with colleagues in a primary health care environment, aimed at forestalling any further progression toward need for acute intervention. Further, there is a very real sense in which the patient is a ‘portal' to their wider context – family members who may be at risk themselves of ill-health but who, through health promotion messages or, for example access to smoking cessation, can be helped early. The Leading for Outcomes framework provides a useful tool for all engaged in delivery of health care to see where they can best work with anyone needing their services. A macro view of societal impact in health status provides the contextual framework needed to effectively engage with people. An understanding of where a person is with respect to the continuum of wellbeing and disease allows nurses to use their particular expertise to derive and deliver the most appropriate and potentially effective intervention. Furthermore, an appreciation of the Outcomes Hierarchy allows practitioners to identify their place in the general scheme of health care provision and understand their relationship with others in that system, be they clinical colleagues, administrators, academics or funders and planners. There is also the opportunity for all nurses, whether they be clinical specialists and nurse practitioners expected to participate in research endeavour or not, to use information gained in practice to influence changes in local health policy so tailoring provision to more precisely match the needs of their population. In summary, the Leading for Outcomes framework gives us a tool to effectively plan interventions for all, irrespective of health and / or disease status, and to see the opportunities for use of our specific skills and competencies in tailoring health care provision to the particular needs of people as individuals, members of families, groups, communities, and wider society. A truly holistic concept.
References:
MoH, 2000. Health and Disability Strategy . Wellington : Ministry of Health MoH, 2001. Primary Health Care Strategy . Wellington : Ministry of Health Further information on Leading for Outcomes from: www.leadingforoutcomes.org.nz
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