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. 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