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Person Centred and Integrated Care Planning


... a personalised care plan for vulnerable people ... Common Assessment Framework. A Common Assessment Framework, building on the Single Assessment Process to ... – PowerPoint PPT presentation

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Title: Person Centred and Integrated Care Planning

Person Centred and Integrated Care Planning
  • Claire Whittington
  • Head of Long Term Conditions
  • Department of Health

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

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

Why bother ? Current care for those with
long-term conditions is not as good as it could
be and does not always meet recommended
  • 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
  • A Healthcare commission survey of patients with
    diabetes suggests these care plans are not being

Source Healthcare Commission Survey of people
with diabetes (2006)
Care Planning
  • White Paper commitment to issue good practice
  • 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

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
  • Emphasises importance of integrated networks and
  • It will not replace or contradict other guidance
    but rather complement it

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

Scope of the Guidance
  • Acknowledge and keep in focus the scope of the
  • 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
  • A framework to allow local adaptation

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
  • Maximises combined potential

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

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

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