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.
Explore joint needs assessment and care planning
- Personalised health and care framework (NSHE)
- Person-centred care and support planning (DHSC 2018)
- What to expect during assessment and care planning (SCIE & NICE 2018)
- Person-centred future planning (SCIE & NICE 2018)
- Personalised care and support planning (NHSE 2017)
- Involving people in their own health and care (NHSE 2017)
- Delivering personalised care and support planning (Coalition for Collaborative Care & NSHE 2016)
- Delivering care and support planning (TLAP 2015)
- Care and support planning guide (National Voices 2014)
Practice examples Open
Measuring success Open
- P3C measures for care planning (Plymouth University)
- P3C measures for for shared decision making (Plymouth University)
- Digital care and support plan standard: final report (PRSB 2018)
- Personalised care planning for adults with chronic or long-term health conditions (Chocrane 2015)
- Integrating social context into comprehensive shared care plans: A scoping review (Nursing Outlook 2017)
- Better care in my hands: a review of how people are involved in their care (CQC 2016)
Latest evidence Open
These are the latest resources from Social Care Online, the UK’s largest database of care knowledge and research.
Learning from the Macmillan Local Authority Partnership Programme
- Social Care Institute for Excellence, 2019
Comprehensive geriatric assessments in integrated care programs for older people living at home: a scoping review
- Wiley, 2019
The Support, Health, Activities, Resources, and Education program for early stage dementia: results from a randomized controlled trial
- Sage, 2019
Development and pilot testing of the “focus on the person” form: supporting care transitions for people with dementia
- Sage, 2019
Better local support for carers: a framework for good practice
- National Development Team for Inclusion, 2019
Armed forces personnel in transition: integrated personal commissioning for veterans (IPC4V)
- NHS England, 2019
Personhood, dementia policy and the Irish National Dementia Strategy
- Sage, 2019
Learning disability: care and support of people growing older: (QS187)
- National Institute for Health and Care Excellence, 2019
Considering the team in team formulation: a systematic review
- Emerald, 2019
Personalised care for veterans in England: a guide for clinical commissioning groups and local authorities
- NHS England, 2019
- Learning from the Macmillan Local Authority Partnership Programme
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.