Patient Knows Best has successfully incorporated the Digital Care and Support plan standard into their templates in order to better support personalised care. A health information exchange, Patient Knows Best brings information from health and social care providers as well as patients’ own information to create personal health and care records. We speak to the organisation’s CEO, Dr Mohammad Al-Ubaydli about using the standard in action.

 

What prompted you to use PRSB’s care plan standard?

We heard from our customers that the PRSB national shared care planning standard is what they wanted. Patients Know Best (PKB) has had the shared care planning functionality available in our application for more than five years – we were the first to enable truly shared viewing and editing, across all providers – including editing by the patient. However, we were looking for a standard to use with our customers and PRSB became the obvious solution.

How was this done? Did you find it straightforward to incorporate the standard in your template?

It was straightforward to do because the standard is specific and Patients Know Best is flexible. So it was easy and fast to create a care plan template in PKB that incorporated each of the elements of the PRSB standard. The PRSB documentation was also helpfully clear and complete.

How is it being used in action? By whom?

Since January 2020, the PKB-PRSB care plan has been available for all our customers. The feedback has been positive. Care planning teams like that they can use a national standard for their clinical transformation with PKB.

What challenges have you faced?

Shared care planning is clinically transformative. Everyone agrees that the patient seeing a care plan is the right thing to do, that planning with the patient improves outcomes, and that working across care settings increases safety. However, providers are still paid to document a care plan in their electronic medical records system, and none of these systems support shared care planning. Furthermore, clinical training programmes are still used in planning ‘for’ the patient not ‘with’ the patient. Transformation programmes tackle the incentives and training.

Do you have any solutions and advice for others hoping to use the standard?

Do it. Start small, start soon, but do it. The majority of health care spending is on long-term conditions, i.e. where the patient does most of the things that affect outcomes. In these cases they must be part of the decisions, plans and actions. More patients have more long-term conditions, so more specialists must help each patient, and care plans must be shared across care settings. These trends are large and long-term. The sooner you adopt shared care planning, the better for everyone, as the problems it solves will only increase.

What are the benefits to people who use services? To care professionals?

We know from previous work with shared planning that this is beneficial to patients and professionals. Patients who received their shared care plan from North Bristol’s severe trauma team improved their patient activation measure (PAM score) which is correlated to improve outcomes and lower costs. GPs had 28% fewer unscheduled appointments within 30 days of discharge from hospital, and the appointments were more efficient as the GP could see from the patient’s record, the same plan the hospital specialists had entered.

Anything you would change?

Communicating to payers that a plan that the patient cannot see and change is not a useful care plan. Nor is a plan that is trapped in one care setting’s record system. That provider may think it is useful to get paid to have written it – but it is not useful to the patient and so, the payer should not pay.