New digital care and support plan standard helping people with long-term conditions

People with long-term health and care needs will soon be able to benefit from a new standardĀ for sharing information among health and care professionals, just published by the PRSB, that is designed to facilitate safer care.

The digital care and support plan standard will support the growing number of people living in the UK with long-term and complex conditions byĀ setting outĀ theĀ keyĀ informationĀ that needs to beĀ gathered, recorded andĀ shared in a care plan.Ā By improving communication between different health and care services, it will enableĀ everyone involved in aĀ personā€™s care to have access to the right information when they need it.

It forms an important part of the national driveĀ to provide people with long-term conditions with aā€Æpersonalised care plan. This includes:

  • maintaining a personā€™s health and wellbeing
  • setting goals for improvement
  • outlining how a person wants to be cared for inĀ a crisis situation.

It was developed with input from a wide range of professionals, carersĀ and the people who useĀ services. TheyĀ agreed what information it is essential to shareĀ in order toĀ provide well-coordinated care that addresses a personā€™s needs and goals.Ā The standardĀ has been published byĀ the Professional Record Standards BodyĀ in collaborationĀ with North West LondonĀ Clinical Commissioning Groups, and the Royal College of Physicians Health Informatics Unit.

OneĀ person involved in developing the standardĀ isĀ Stella Smith, a professional social worker and parent carer. Speaking about the new development she said: ā€œMy son Andrew was diagnosed with an autism spectrum condition as a child. He has received helpĀ and support from many different services, but in the past weā€™ve faced challenges in joining these up. A digital care and support plan will mean all his information, needs and future goals will be outlined in one place, making it easier for professionals to work together to help him achieve his goals.ā€

As well as supporting carers, the standard will alsoĀ empowerĀ people using services to become more involved in their own care. ā€œThis is the first care and support plan of its kind and we will see the development of more specialist plans in future,ā€ said Professor Maureen Baker CBE, chair of the PRSB. ā€œIncreasingly people want to take ownership for their own health and care.Ā  Better information sharing between different services and the people using those services will help this happen.ā€

To find out more please contact info@theprsb.org

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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.