Person Centred and Integrated Care Planning

1
Person Centred and Integrated Care Planning

• Claire Whittington
• Head of Long Term Conditions
• Department of Health

2
The commitments

• Public Service Agreement (PSA) target
• To improve health outcomes by offering a
  personalised care plan for vulnerable people most
  at risk, and to reduce emergency bed days by 5
  by 2008 through improved care in primary care and
  community settings.
• Our health our care our say commitments
• By 2008 everyone with both long term health and
  social care needs will have an integrated plan if
  they want one and by 2010 everyone with a LTC
  will be offered a care plan.
• And underpinned by
• By 2008 all PCTs and LAs should have established
  joint health and social care managed networks
  and/or teams to support those with long term
  conditions who have most complex needs

3
Common Assessment Framework

• A Common Assessment Framework, building on the
  Single Assessment Process to ensure less
  duplication across different agencies, avoid
  fragmentation and facilitate information sharing
  across health and social care
• Developing a standard information set for CAF as
  well as guidance for its use
• CAF domains based on Outcomes (Independence,
  Well-being and Choice)
• For the individual and their carer
• Aligned to Fair Access to Care Services (FACS)
• Supports a person centred approach Self
  Assessment/Involvement

4
Why bother ? Current care for those with
long-term conditions is not as good as it could
be and does not always meet recommended
guidelines

• NSF guidance recommends that patients with
  diabetes should agree to a care plan to manage
  their conditions, as the best results are
  achieved by
• patients who are engaged in their own care
  empowered to manage
• Organised diabetes teams that actively seek out
  people to ensure they get the best care.
• Partnerships between people with diabetes
  healthcare professionals to solve problems/plan
  care
• A Healthcare commission survey of patients with
  diabetes suggests these care plans are not being
  agreed

Source Healthcare Commission Survey of people
with diabetes (2006)
5
Care Planning

• White Paper commitment to issue good practice
  guidance
• Expert Reference Group of key stakeholders held
  May 2006
• Assessment and Care Planning Policy Collaborative
  also shaped its development
• Linking across to work on Integrated Networks and
  Teams

6
Aims of Care Planning Guidance

• Support delivery of the Long Term Conditions PSA
  target and the White Paper commitments
• Promote good care planning leading to improved
  care/support for people
• Bring together learning from good practice into
  one document
• Describe the key principles for person centred
  approach
• Emphasises importance of integrated networks and
  teams
• It will not replace or contradict other guidance
  but rather complement it

7
Key areas

• The agreed principles of person centred care
  planning
• How it links with assessment
• Care coordination
• Why important for commissioners
• Benefits and the impact on different sectors
• Integrated teams/networks
• Key actions

8
Scope of the Guidance

• Acknowledge and keep in focus the scope of the
  guidance
• To describe an overarching framework for care
  planning that can be adapted by heath, social
  care and third sector organisations
• Avoid too much detail, we cant describe
  everything
• A framework to allow local adaptation

9
Integrated teams/networks what will the
guidance say ?

• Effective care planning requires integration of
  health and social care at individual and
  strategic level
• Critical to coordinated, seamless approach to
  care planning and delivery
• People with complex needs often require
  multi-disciplinary/multi-agency support
• Person-centred care enabler to joint working as
  ensures all members of team have shared
  understanding of persons needs and desired
  outcomes
• Maximises combined potential

10
Individual - Integrated teams

• Not prescriptive
• Teams based around user needs
• Planning and delivering care across
  organisational boundaries
• Fixed and/or virtual, but communicating regularly
  about defined group of individuals
• Involve support from specialists as appropriate
• Promotion of where working well and tools to help

11
Strategic - Integrated networks

• Commissioning for people with LTC complex
• Integrated Networks need to be at centre
  informing planning and commissioning of care
• Bring together clinicians, users and managers
  across health and social care
• Subgroup of PCT and LA with leading role in
  identifying priorities and managing cross
  boundary issues
• Senior accountable officers from PCT and LA to
  lead network
• Reporting to joint commissioning arrangements

12
Next Steps

• Publication
• Further guidance for workforce/patients
• Links to world class commissioning