Reaching new heights with highly personalised care

A guest blog by Rob Hardisty, Solution Director at Graphnet Health.

What is integrated care’s next big move? I believe the obvious next step is using digital tools to help people record and share what they and/or their families consider their most important information while they are being cared for.

Using IT as an enabler, combined with joined-up personalised care, we have the potential to elevate care to new heights while supporting tomorrow’s NHS as it increasingly relies on people being more involved in their care to reduce the strain on services.

How did we get to this pivotal moment?

During the initial phase of digitising health information, the emphasis was on eradicating paper and digitising local care records to support an individual’s care. Fast track to today and the priority is joining up an individual’s care information from various health and social care organisations across Integrated Care Systems (ICSs).

There’s still lots to do in this phase but the evidence from frontline care is already compelling. Working with our strategic Care Alliance partners, System C and Liquidlogic, we have put interfaces in place between social care systems and health systems for a number of our customers, which are in use today, facilitating more collaborative working.

The benefits of integrating health and social care information across care systems for people and care professionals are clear and the potential to use powerful, actionable data insights for population health, is already being realised by several of our customers.

Both integrated health and social care and population health will elevate a care system’s service offer significantly, but there is potential to raise the bar further. Implementing information standards consistently, such as the About Me profile, to personalise an individual’s care will be the next step to improve care even more.

Shifting the perspective to personalised care

The shift to personalised care is the driving force behind our investment in developing information standards across our solutions and why we have joined forces with the Professional Record Standard Body (PRSB).

Graphnet has been developing its information standards alongside its shared care record and population solutions for some time.

In 2017 we saw an opportunity for an integrated module within our integrated care record solution to share information about an individual which isn’t normally captured in clinical systems. At the time, there were myriad different hospital-/health-/personal- passports, say it once, all about me variations; with over 20 different versions in use at one point in the UK.

It was at this point that we collated patient, citizen and care team feedback to create our own integrated personal passport with six key headings. Through patient engagement workshops, these were refined down to three key headings:

  • I want you to know – top likes and dislikes, most important things to me, perceived strengths and weaknesses
  • Important things to know in an emergency – contacts, wishes known and discussed with family, future care wishes
  • How I live – more information about their living details than is usually available, what personal support they have, etc.

These were all brought together under the heading of “All About Me” within the myCareCentric Personal Health Record (PHR).

The power of this module is that it enables the individual to record in their own words what they feel is important, what they think is missing from their clinical records and in their own words what their hopes and aspirations are with regards to their care. If they also have an Integrated Care and Support Plan, this information saves the clinical team time and gives them an insight into how the individual is thinking; perhaps what is important to them is not the same as the standard pathway goals.

We found that the main part of our “All About Me” was very closely aligned with the PRSB’s “About Me” section of the Personalised Care and Support Plan and so with a small amount of configuration re-design we could be completely aligned. Further amendments were made as the standard evolved, and our users know that we are following the latest national guidance. The other parts of our module are still important to our users, and we were able to feed that back to the PRSB team. We see that two-way collaboration as being key and why we wanted to join their Standards Partnership Scheme.

Strength in partnership working

Graphnet joined the scheme at the beginning of the year but more recently the whole System C & Graphnet Care Alliance decided to follow suit, after seeing the strong relationship and progress we have made since partnering. The About Me standard is just one part of Graphnet’s work with the PRSB. We are working on a number of standards and developments to align our solutions and the Alliance is extending this work to support the implementation of standards across its integrated IT solutions for social care and education management, electronic patient records, medicines management and remote monitoring.

Today the About Me standard is implemented across six of our customers covering approximately ten million care records. During COVID-19 monitoring, About Me and the corresponding sections were used thousands of times by patients and care teams, particularly during winter 2021/22.

About me guided principle

Our “about me” approach helps us to better design new content. The needs of the individual may not always align with set care plans, so we need to be mindful of allowing the person to record what they want to record in their own way. We make it clear that this is not directly monitored but that it is available at the point of care, as and when it is needed. The tight integration between shared care records and the PHR, along with the close relationship with the PRSB, are key elements of our approach.

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Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.