Person Centred Software: Implementing the About Me standard to enable personalised care in more than 3,000 locations

Person Centred Software provide a digital care record and evidence of care solution to approximately 3,000 care locations across the UK and Australia. The organisationā€™s customer base constitutes a variety of care settings supporting older people, those living with dementia and those with nursing needs, as well as services supporting younger people with learning requirements.

The organisation has developed a feature called Who I Am; a tool that provides carers with the information they need to determine how best to support the individual. The tool is mobile and eradicates the need for those administering care to repeatedly return to computer terminals to gather information on individuals they are supporting. In implementing the PRSBā€™s About Me standard, Person Centred Softwareā€™s CEO, Andrew Coles, and his team wanted to enhance the product further.

ā€œPeople are at the heart of everything we do, from the people receiving care to the people providing care,ā€ explained Coles. ā€œAll will have different encounters with different healthcare professionals throughout their life, and one of the key aims of the About Me standard is to improve these journeys and ensure a continuity of care. We are continually evolving and improving the solutions we offer, and there are many things we could do, but the About Me standard matched the philosophy of our business 100% and so implementation was a no-brainer.ā€

In embarking on a programme of change, it was important for Person Centred Software to consider other stakeholders likely to be impacted. Those using the tool were prioritised in this regard, and Colesā€™ team wanted to ensure implementation of the standard made a difference in improving the lives of end users.

ā€œHow do we take tens of thousands of users on a journey without having to retrain them? Our users demand that we meet their evolving needs, but any change management processes need to take place with limited disruption. This was one of our major challenges, as it would be for any software supplier.ā€

ā€œMeanwhile, itā€™s important for us to deliver against the promises and commitments we have made to be part of the NHS assured supplier list for digital care records. But we knew that we would be able to achieve widespread coverage and use of the About Me standard, and we knew it would make a big difference.ā€

Person Centred Software had already made great progress in the development of the Who I Am tool prior to implementation of About Me, and the organisation found itself already conforming to many elements of the standard. The software was built in such a way that allowed for iterative future development and this was helpful in making changes quickly and efficiently. But the conformance process helped Coles and his team ensure the tool was delivered in a way that proved more impactful for the end-user. It flagged changes that took little more than four weeks to implement.

ā€œThe conformance process with PRSB was supportive. It was helpful and made sense, and it was clear that implementing a standard shouldnā€™t be done purely from a data perspective. Instead, it should be viewed as the means to provide a tool that can be used and which delivers best practice.ā€

Andrew Coles on the About Me standard conformance process.

ā€œOur role is to understand how technology and software works alongside people. This shone through in the conformance process and helped us realise the importance of co-designing and engaging with end-users. You could really see how About Me integrates and is not just functioning in isolation. Itā€™s a living and breathing tool that adapts and should be used and updated daily as opposed to set and forget.ā€

With the Who I Am feature hosted as a Software as a Service (SaaS) solution, Person Centred Software are able to deploy updates to all users instantly and seamlessly. ā€œWe were able to achieve widespread adoption of the standard by making the required changes fit the solution in an intuitive way, working alongside regular day-to-day working practices.ā€

The About Me standard has benefitted Person Centred Software by bringing person-centred care to the forefront of conversation. Since launch of the Who I Am tool in 2019, more than 11,000 About Me profiles have been created.

ā€œWhenever providers are considering which solution best fits their business needs, itā€™s common for the care team operating on the front line to be considered first and foremost. Like Person Centred Software, those making the decision tend to focus primarily on the person themselves. Implementation of the About Me standard has helped demonstrate our commitment to the individual and this really resonates with customers, giving us an edge over the competition.ā€

ā€œOur customers have benefitted from our implementation of the standard as it has improved the lives of both those receiving and delivering care. It has bred confidence in what individuals require within their care programmes.ā€

Case Study: Berhard Baron Cottages

Implementing mobile care monitoring has helped carers at Bernhard Baron Cottages provide support quickly and effectively to prevent situations from escalating, and resulting in a less stressful experience for all.

ā€œThe Who I Am feature in Mobile Care Monitoring helps us to support our residents. We have a resident that has mental health issues and suffers with anxiety. Thereā€™s a prayer that she likes to read when sheā€™s anxious. Itā€™s really good to have that information available for all staff under the ā€˜What makes me feel better if Iā€™m anxious or upset?ā€™ section of the Who I Am feature.ā€

Jasmine McFetters, Carer, Berhard Baron Cottages

Case Study: Tilsley House

Implementation of the About Me standard can also prove critical in transfers of care scenarios, as demonstrated by this instance at the Tilsley House care home. When the person moved, they were able to get the same level of care they had been receiving previously as a result of the rich information travelling with them.

ā€œWhen one of our ladies with dementia had to go to hospital, we provided a pack with all the details from the Who I Am document to aid staff providing her care. A hospital nurse got in contact with us to say it was the best information she had seen.ā€

Shari Tindle, Deputy Manager, Tilsley House

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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.Ā 

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.Ā 

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 providesĀ 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.