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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:

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Person Centred and Integrated Care Planning

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  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. Keyareas • 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 can’t 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 person’s 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

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