Integrated care and support planning

Integrated care and support planning

 

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Integrated care and
support planning

Nilesh Bharakhada

Date: 30th May 2017

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In recent years, the UK has witnessed an increase in the number of people living with chronic medical conditions, and treatment options are becoming ever more complex.

To ensure people are getting the best possible care, it’s essential that they have good care planning from different health and care professionals. The complicated nature of diabetes, chronic obstructive pulmonary disease and heart failure to name a few requires a multidisciplinary approach to managing people’s care. Rather than just GP and hospital care, patients receive expertise from a wide range of allied health and care professionals from occupational therapists to physiotherapists, district nurses, community matrons, consultants and adult social care. To facilitate the best possible holistic care, we need a joined-up approach, where relevant information on a patient’s condition can be shared quickly and easily. Integrated care planning allows care to be effectively coordinated, so that multi-disciplinary teams can deliver person-centered care that addresses their preferred treatment plan.

Working in collaboration with the North West London Collaboration of Clinical Commissioning Groups (CCGs) the PRSB has begun developing the Integrated Care and Support Plan Standard to ensure that care plans can be effectively shared between patients, carers and all health and care professionals involved in the person’s care. The standard will also help to support self-care and allow health professionals to deliver person-centred care.

To create a shared care and support plan, we have to agree what information it should contain, what its structure should be and how individual care planning components should be held so they are accessible to care providers. We also need to consider how health and care professionals can update the care plan and how care providers are alerted to any changes specifically relevant to them.

Once the standard is agreed, NHS Digital will develop technical specifications, based on the project outputs. The plan is for these specifications to be incorporated into standard clinical IT system contracts, like GPSoC, to build capabilities into acute hospital, GP, community, mental health and social care systems, with the aim of enabling electronic sharing of care and support plan information. North West London Collaboration of Clinical Commissioning Groups (NWL CCGs) is one of the national integrated care pioneer sites, and this pilot will support implementing a standardised care and support plan across the whole health and social care system.

When a generic care and support plan is agreed, it will be possible to create more specific care plans for a range of conditions including chronic conditions and end-of-life care. Increasingly, patients with terminal conditions are deciding on the care they want, with organisations like Dying Matters advocating open discussions about end-of-life care and patient-led decisions. Whether a condition is chronic or terminal, sharing a care and support plan will ensure that all staff and carers involved in a patient’s care will have access to the right information when they need it, in order to personalise care and improve the experience for the patient, their carer and their families.

The new project will build on existing national and international work on integrated care planning, working closely with members of the RCGP collaborative care and support planning network, the North-West London Collaboration of CCGs, the Healthy London Partnership, NHS Digital as well as national representative professional bodies and Royal Colleges. The PRSB will be working closely with a range of clinicians, professionals, carers and patients across the UK, to develop a standard that is applicable in England, Wales, Scotland and Northern Ireland. At the moment we are gathering evidence and good practice examples and seeking contributions from professionals across health and social care. If you’d like to contribute, please contact us atinfo@theprsb.org.

The second phase of the project will include a consultation process and workshops, before the standard is put together ready for review.

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    CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

    1. Understanding the artefacts that characterise the group and its activity.
    • The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

    2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests. 
    • Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

    3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history. 

     

    • ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

    4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning. 

    This links to the fifth principle that:

    5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”