About me case study – Cassie’s story

About Me - Cassie's story

This case study focuses on Cassie, a 69-year-old with learning disabilities who lives in her own self-contained flat with an ‘extra-care’ supported living service provided by Havencare.

Sharing information on how to communicate with Cassie using the About Me Standard enables hospital staff to understand her health procedures and provide care that meets her needs and requirements.

Multi Me is a secure online platform for individuals with disabilities and the circle of people that support them in their daily lives. They have achieved conformance with ‘About Me’, which shows their commitment to standards excellence and robust information sharing, resulting in better health and care outcomes for people.

On this page

The challenge

Cassie has liver failure and has been on the transplant list for many years without success. In early 2024, Cassie became seriously unwell and needed to stay in hospital for 4 months.

During this period, her 1-1 personal support from Havencare would attend the hospital for a few hours each day, but the remaining time, she was under the care of the hospital nursing staff. Especially when unwell, Cassie struggles to express her needs and wishes.  

Woman in hospital being given lunch

The solution - 'About Me'

wiki case study

The PRSB’s About Me Standard includes most important details that a person wants to share with professionals in health and social care. This information might include how best to communicate with the person, how to help them feel at ease or details about how they like to take their medication. 

It is intended to be generic and apply to everyone, from those who have complex care and support needs to those who rarely require care and/or support. 

Using ‘About Me’ information has been shown to achieve huge benefits for people including supporting them through hospital appointments or other care which might not have been possible or resulted in adverse outcomes without understanding key ways to work with the person.

The process

Sharing About Me information
Cassie’s support team shared the information from the ‘About Me’ section of her plan (recorded in her Multi Me Wiki) with the hospital staff.

Wikis are simple, accessible, and easy to build personal websites. They can be used to create multimedia person-centred plans that use pictures, words, video and sound to capture the voice, skills, aspirations and needs of the individual.
Improving care for Cassie
Due to the quality of the about me information in her support plan, specifically the “how to communicate with me” section, visual aids were used to support Cassie, alongside her Independent Mental Capacity Advocate (IMCA) to understand her health procedures.

The hospital staff were also given key information on how to use social stories with Cassie to help her understand important information and decisions.
Cassie's Wiki
The results
Sharing Cassie’s ‘About Me’ information, helped her feel much more settled in hospital, reduced her anxiety, and helped the hospital team engage with her positively with kindness and familiarity.

Cassie returned home after hospital and is making the most of her time given her health situation. Havencare believes that sharing this information was key to Cassie’s recovery and her being well enough to be able to return home.

Feedback

“Re-traumatisation can easily happen in health and social care as people are not treated with individuality or understanding of their lived experience. In Mike’s case, it is reasonable to assume that without shared About Me information in Multi Me, there would have been delays and miscommunication that would have caused distress and the potential for serious incidents. I believe the PRSB's About Me Standard humanises people’s interactions with the system, offering the potential to raise the equality of access to better health outcomes for all people”.
Phil Morris
Phil Morris
Chief Executive, Havencare Homes and Support
"It has been an incredibly positive experience working with Havencare to implement the PRSB About Me Standard. Utilising a template that adheres to the About Me implementation guidelines is an excellent method for gathering truly person-centred data. This approach significantly enhances the quality of care and support provided to those under Havencare's services. Multi ME, in collaboration with our partners at RIX Inclusive Research, is proud to be part of the PRSB's Standards Partnership Scheme, and we look forward to continuing our efforts to improve care standards.”
Charlie Levinson, CEO
Charlie Levinson
CEO, MULTI ME

Resources

The About Me Standard
View the full standard and supporting documentation, examples and other resources.

Conformant partners
Find out which of our PRSB Partners have successfully achieved conformance against the About Me Standard.

Support services
Proactive support for our standards and ongoing maintenance and release management of published standards. 

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.