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Joint needs assessment and care planning – Activities to achieve integrated care

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.

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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.

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