Joint needs assessment and care planning
What is joint needs assessment and care planning?
Personal planning involves listening carefully to people experiencing care and having good conversations, including others that may be important, for instance families and carers. This involvement helps to promote people's rights, needs and choices through a clear and accessible written and visual plan.Care Inspectorate 2021
In the past, individuals and their families were asked to undergo assessments of their health and/or social care needs by each professional who became involved. Whilst some aspects of such assessments may have differed due to the specialist nature of the service and treatment on offer, much was in fact similar across all professionals. This meant that the individual had to repeat their details and stories on multiple occasions which took up much of their time, could unnecessarily delay access to support, and could require the sharing of personal and distressing information to numerous people. Professionals then used these assessments to develop their own care plans which did not sufficiently connect with and co-ordinate across those developed by other professionals.
Joint needs assessment and care planning involves introducing pathways and tools which ensure that information which is common across multiple professionals is gathered and analysed through inter-disciplinary processes. This is then used to develop common care plans in collaboration with the individual and their family.
Video transcript Open
What is joint needs assessment and care planning and how does it support integrated care?
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.
Undertaken by multidisciplinary team and involving service users this leads to well-coordinated care plans and meeting individual’s health and wellbeing needs. Tailored support can be put in place for people at home and community services can respond during crises when their needs change.
Well-coordinated care from a range of local services also smooths transitions between care environments and improves the overall care experience.
Who's involved in joint needs assessment and care planning?
Multidisciplinary teams with a lead assessor ensure the processes used are effective and consistent. What makes care plans personal is the direct involvement of people and their carers in the needs assessment and planning.
Personalised care plans will include a range of community services from preventive to urgent care often provided in the home. Plans are expected to keep people well and wherever possible out of hospital and other institutional care.
What does successful joint needs assessment and care planning entail?
Successful joint working requires preparation and training for the whole multidisciplinary team. These health and social care professionals will also need to learn effective methods for involving service users and supporting shared decision-making.
Success also depends on standardised approaches to assessment, good communication within the team and access to shared care records.
What is the evidence for outcomes and impact?
Studies have shown a number of benefits for joint care assessment and planning including the improvement of physical and psychological health status. People with chronic illnesses have been shown to improve their confidence and skills to manage their health. A few studies are showing a reduction in emergency department visits and the avoidance of hospital admissions.
Explore joint needs assessment and care planning
- How can skill-mix innovations support the implementation of integrated care for people with chronic conditions and multimorbidity? (World Health Organization 2022)
- Social work with adults experiencing complex needs (National Institute for Health and Care Excellence 2022)
- NHS continuing healthcare decision support tool (Department of Health and Social Care 2022)
- Guide for providers on personal planning: adults (Care Inspectorate 2021)
- Making sense of coordinated care (Health Education England 2019)
- Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services (WHO 2018)
- Person-centred care and support planning: a guide to efficient and effective interventions for implementing the Care Act 2014 as it applies to carers (ADASS 2019)
- Making it Real: how to do personalised care and support (TLAP 2018)
Practice examples Open
- Supporting admission avoidance in Hertfordshire (NHS Confederation 2022)
- Integrating health and social care: North East Lincolnshire case study (LGA 2018)
Measuring success Open
- Evaluating personalised care guide (SCIE 2020)
- How to understand and measure impact of integrated care (Better Care Fund 2019)
- P3C measures for care planning (Plymouth University 2016)
- Provider and manager perspectives on the use of an integrated clinical pathway for community-dwelling older adults: a qualitative case study (International Journal of Integrated Care 2022)
- In the centre or caught in the middle? Social workers' and healthcare professionals' views on user involvement in coordinated individual plans in Sweden (Health and Social Care in the Community 2022)
- Assessment and management pathways of older adults with mild cognitive impairment: descriptive review and critical interpretive synthesis (Health and Social Care Delivery Research 2022)
- Engagement and inclusion of individuals with a dual sensory loss and learning disability in the assessment process – staff perspectives (Practice: Social Work in Action 2022)
- Electronic information sharing between nursing and adult social care practitioners in separate locations: a mixed-methods case study (Journal of Long-Term Care 2021)
- Evaluation of the Integrated Personal Commissioning (IPC) Programme: final report (SQW 2019)
- Comprehensive geriatric assessments in integrated care programs for older people living at home: a scoping review (Health and Social Care in the Community 2019)
- Choosing the harder road: naming the challenges for families in person-centred planning (Journal of Intellectual Disabilities 2019)
Latest evidence Open
How does joint needs assessment support integrated care?
The key benefit of coordinating care is that people 'see the right person, the first time' without having to repeat their story or having to be referred on time and again, wasting time and resource for all and risking deterioration in their wellbeing.Health Education England 2019
A joint approach can facilitate greater communication between professionals as they all have access to the relevant information from an individual and can gain a better understanding of the perspectives of other professionals. It facilitates greater involvement of the individual and their family in the process through making transparent the need for the information and how it will be used by health and social care professionals and services. Shared planning processes help to ensure that there is not duplication across professionals and services, there is better coordination over what is to be provided, and that formal care better integrates with informal networks and community resources. As a result, joint needs assessment and care planning helps to ensure that the greatest benefits for the individual and their family is achieved.
What does joint needs assessment and care planning need to succeed?
Building the competence of the health and care workforce to deliver continuity and care coordination prepares them for their specific roles and responsibilities in prevention and enablement, proactive case management, navigation, goal-centred care planning, advocacy and interdisciplinary practice in different professions, teams, settings, specialities, and sectors. Appropriate education and training should also be provided for patients, families, carers, volunteers, and community partners.WHO 2018
The starting point for the development of more integrated pathways is to understand what is important to people who may need to access such support. These insights can then be combined with research evidence, good practice guidance and the views of practitioners through a co-produced process. The integrated pathway should be supported by digital care records and common documentation which is accessible to the relevant disciplines and agencies. Professionals need related training and guidance on how to use the new processes and how they can contribute to the pathway. Opportunities to connect across disciplines, potentially through multi-disciplinary teams, help to facilitate discussions on how to use the processes and how their individual support and expertise can be co-ordinated around the person. Individuals and families who may access support need accessible information on the purpose of these processes and, particularly for those with more complex and long-term needs, training and support on how they can engage with the assessment of their needs and in decision-making over their support.
What is the evidence for outcomes and impact?
A quarter felt that their new personalised care and support plan gave them a lot more support than before and 31 per cent felt it gave them a little more support. Analysis of the standardised measures found that there was no statistically significant improvement in health outcomes (measured through EQ5D) and in general wellbeing outcomes (measured through WEMWBS). There was, however, a significant improvement in the social care related wellbeing outcomes (measured through ASCOT).SQW 2019
Successful implementation of a shared electronic record between nursing and adult social care practitioners was achieved, demonstrating the importance of involving staff in the design and implementation of changed administrative processes. Electronic information sharing permitted more timely service delivery by promoting more efficient processes within formal working structures.Journal of Long-Term Care 2021
Research confirms that if well implemented, joint assessment and care planning can result in individuals and families being more aware of what support is available to them and having greater opportunity to make decisions over what care and treatment is provided. This can lead to improved experience and wellbeing in relation to the services received and greater confidence in how people manage long-term conditions and disabilities. Evidence also suggests that by themselves such processes will not substantially improve someone’s overall wellbeing as this is related to much wider factors, and that joint approaches may uncover unmet needs which can result in increased support in the short term. Better co-ordination of care plans can facilitate efficiencies through reducing duplication and more effective service delivery.