Nilesh Bharakhada
Date: 30th May 2017
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.
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.
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.
