Joint needs assessment and care planning

What is joint needs assessment and care planning?

For people with multiple long-term conditions and complex needs, the delivery of integrated care starts with a joint needs assessment and care planning approach. There are two ways to understand the ‘joint’ aspect of these processes - they must be undertaken by a multidisciplinary team and produced with the direct involvement of people who use services and their carers.

Multidisciplinary teams are accountable for joint needs assessment and care planning, while lead assessors ensure the processes used are effective. Well-trained multidisciplinary teams use consistent approaches. Their joint working practices are then able to produce personalised care plans for individuals in their care, with each plan enabling a range of community services to be coordinated, from preventive to urgent care.

The meaningful involvement of individuals and their carers in decisions about care priorities supports person-centred care and better care outcomes, including keeping people at home and out of hospital wherever possible. By taking the service user’s own expectations and capabilities into consideration, the personalisation of care plans supports both social prescribing and self-management.

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How does joint needs assessment support integrated care?

Joint needs assessment and care planning lead to care plans that meet individual needs and to services that are well-coordinated to maximise health and wellbeing.

In many ways, joint assessment and care planning mirror the expectations for joined-up service delivery.

  • First, these processes put the person’s individual care needs at the centre of care planning. By using strengths-based approaches, they also take steps to ensure plans are co-produced with service users, holistic and personalised.
  • Second, they enable the coordination of care from a range of local services, thereby reducing the fragmentation of care, smoothing the process at transitions of care and improving the overall care experience.
  • And third, they put in place tailored support for people at home or during crises when their needs change. This helps keep people well, living in the community and out of hospital.

What does successful joint needs assessment and care planning entail?

Research highlights several factors associated with successful joint assessment and care planning:

  • Professionals are committed to involving service users and their carers, and they actively support shared decision-making.
  • Professionals have been adequately prepared and trained to work jointly, and they have acquired new skills and behaviours, e.g. motivational interviewing and patient activation.
  • The assessment, planning and care coordination processes are supported by a practice culture that is team-orientated and person-centred.
  • Personal care records are readily shared across the multidisciplinary team and care providers, with standardised documentation practices.

What is the evidence for outcomes and impact?

Studies of joint needs assessment and care planning have demonstrated that these processes can:

  • improve certain indicators of physical and psychological health status, including symptoms in depressed adults
  • augment the management of chronic illnesses and increase people’s confidence and skills to manage their health
  • have positive effects on care delivery metrics, including higher rates of adherence to treatment, fewer emergency department visits and, where high needs patients are specifically targeted with preventive services, fewer hospital admissions
  • align care with patient goals and foster collaborative approaches to care.