1

Column

What do you do to ensure that a person doesn’t have to repeat themselves unnecessarily?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
A single person with responsibility for coordinating all care Yes Working well
Sharing a plan of care/ appropriate information within your team Yes Working well
Sharing a plan of care/ appropriate information across teams None
A shared care plan document within your team Yes Working well
A shared care plan document across teams None
MDT / Clinical meetings Not Relevant
Discharge planning None

2

Column

Which of these is available to empower people?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Providing information sheets Yes Working well
Signposting to the 3rd sector Yes Working well
Referrals to other services Yes Working well
Referrals to peer support groups Yes Working well
Pharmaceutical support No

3

Column

Do all people who could benefit for P3C have a co-created single personalised care plan in the form of a written document and are they given a copy of their care plan?

_Personalised care plan__ {data-width=600}

Given a copy

Column

Your results

Options Objective
Within teams Most
Across teams None
If no, why not? systems currently not in place
Are they given a copy of there care plan? Yes

4

Column

In general, which of the following elements are included in the co-created plan of care (this can either be in the form of a written document or a plan of working)?

Objective data

Subjective data

Column

Your results

Options Objective
A lead coordinator Yes
A contingency plan for crisis episodes or exacerbations of their condition Yes
A named person to contact in a crisis Yes
An action plan to attain their health goals Yes
An action plan to attain their social goals
Details of who is responsible for what Yes
A List of medications and instructions for when to take Yes
A date for review Yes
Treatment Escalation Plan
None
Not relevant
Options Subjective
How well are your care plans working? Working very well

5

Column

Who normally takes the lead for care planning/ care coordination?

Objective data

Subjective data

Column

Your results

Options Objective
Managerial lead Yes
Clinical lead
Team coordinator
GP Yes
District/ Community Nurse Yes
Community Matron
Community Therapy teams
Social workers
Care workers
None
Not relevant
Other, please specity:
Options Subjective
How well is this working? Working well

6

Column

How is shared decision making with individuals supported in your organisation?

Objective data

Subjective data

Column

Your results

Options Objective
Individual and practitioner work together to set goals Yes
Longer appointment times
Decision aids
Information sheets Yes
Measurements of patient experience of shared decision making Yes
Personal budgets
None
Not relevant Yes
Other (please specify)
Options Subjective
How well is shared decision making working in general in your organisation? Working well

7

Column

How do practitioners specifically elicit goals related to people’s health and social aims?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Personalised care plans structured around the identification of goals Yes Working well
Goals prompted in a separate section of the written personalised care plan None
Some practitioners trained to provide guided conversations None
Longer appointment times None
Using best interest (e.g. Power of Attorney or formal advocate) None
Other (please specify)

8

Column

How do practitioners ensure that people are supported to achieve their individualised social goals?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Conversations with the individual to review goal achievement Yes Working well
The auditing of the plan of care None
The use of additional support (for example health trainers, peer support, coaching, advocacy services or the voluntary sector) Yes Requires some improvement
The use of tools to help people track whether they are achieving their goals (for example, a diary, checklist, charting changes such as weight, health apps) None
Other (please specify)

9a

Column

How is support tailored to the person’s ability and motivation to manage their own health?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Use of a patient measure of activation (e.g. PAM) Yes Working well
Use of activation measure score as part of the care planning process None
Health coaching to support self- management Yes Working well
Peer to peer support None
Group based training for self-management Yes Working well
Disease specific training Yes Working well
Other (please specify)

9b

Column

How are self-management scores (e.g. PAM) fed back into practice?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Gathered externally and never included in records None
Gathered externally and included in records but rarely used Not relevant
Used informally in care planning None
Structured within the care plan None
Other (please specify)

10

Column

In what ways is consideration routinely given to understand how mental wellbeing affects peoples physical conditions, and of the role of physical wellbeing on mental health?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Through Longer appointment times None
Personalised care plans structured to address this None
Mental health workers link into the team None
Other (please specify)

11

Column

How are informal carers assessed and offered support?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Identification of the carer population Yes Requires some improvement
Carer health and wellbeing assessment Yes Requires some improvement
Providing advice and signposting to support services Yes Requires some improvement
Provision of respite if required None
Other (please specify)

12

Column

With what other teams do you have agreements in place to enable partnership working and provide joined up care?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Community based hub or team specialising in LTCs Yes Requires some improvement
General practice
Nursing specialists (e.g. District/ Nurses/ Community Matrons)
Mental Health services
Community Therapy teams
Paid care providers (e.g. care agencies)
Voluntary sector providers
Social Work teams
Emergency Department
Community based admission avoidance teams
Intermediate care team
Residential/ care home providers
Other (please specify)

13

Column

Do multi-disciplinary team meetings take place to identify the most appropriate services and interventions for people suitable for P3C?

Do multi-disciplinary team meetings take place to identify the most appropriate services and interventions for people suitable for P3C?

Who attends these meetings?

Column

Subjective data

Column

Your results

Options Objective
Do multi-disciplinary team meetings take place? No
General practitioners
Practice nurses
District nurses/ Community Matrons
Mental health services
Acute care providers
Social workers
Care workers
Voluntary sector (e.g. Age UK)
Physiotherapists
Occupational Therapists
Pharmacist
Medical Consultant
Other (please specify)
None
Not relevant Yes
Options Subjective
How often do these MDT meetings happen? Not relevant
Other (please specify)

14

Column

Are processes in place to allocate roles and responsibilities across and within teams?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Are processes in place to allocate roles and responsibilities across and within teams? No
Processes in place for a single named person coordinating the support and care of each person suitable for PCCC WITHIN teams
Processes in place for a single named person coordinating the support and care of each person suitable for PCCC ACROSS teams
Across team agreements to work together on a single care plan
Processes in place to ensure continuity of care/ care transitions (please specify in the comments box below)
Processes in place for active Mental Health Team input

15

Column

Which practitioners act according to the personalised care plan?

Objective data

Subjective data

Column

Your results

Options Objective
GP Yes
District/ Community Nurse Yes
Community Matron
Mental Health Team
Social Workers
Care workers (e.g. agency workers)
Nominated 3rd sector providers
Physiotherapists
Occupational therapists
Consultant Specialists
Other (please specify)
Plans are used but not personalised
Plans are not used
Not relevant
Other (please specify)
Options Subjective
How well is this working? Requires some improvement

16

Column

How do you provide proactive case management (identification, assessment, planning, monitoring and coordination)?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Use of predictive models to identify who will benefit from PCCC No
Appointments are available for crisis care No
Appointments are available for proactive care No
Multi- Disciplinary Team (MDT) meetings to discuss complex cases No
Systematic review of caseload/ list No
Allocation of an individual from MDT with responsibility to ensure ongoing care No
Other (please specify) Not working

17

Column

For which groups do you measure the experience of care:

Objective data

Subjective data

Column

Your results

Options Objective Subjective
People suitable for PCCC Not relevant
Families of individuals suitable for PCCC Not relevant
Carers of individuals suitable for PCCC Not relevant
Other (please specify)
Use Response
How do you use the measures from Q17a to inform the delivery of care/ support?

18

Column

What systems are in place to identify and allocate people suitable for P3C?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Risk stratification and automatic allocation Not Relevant
Risk stratification and allocation by team agreement Not Relevant
Agreement by team providing PCCC Not Relevant
Routine discharge screening Not Relevant
Ad hoc clinical complexity identified by practitioner Not Relevant
External practitioners/services refer in Not Relevant
Other (please specify) None

19

Column

Which approaches are used to organise the care of those identified for P3C?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
A lead practitioner takes on case management role for each individual Yes Working well
People’s needs and treatment are reviewed regularly Yes Working well
The need to step up/ down intensity of input reviewed regularly None
MDT meetings None
Regular review of case load allocation Yes Working well
Other (please specify)

20

Column

What contact/ appointment arrangements are in place to support P3C?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Appointments specifically for PCCC planning None
Longer appointments available on request for routine care None
Home visits for PCCC planning None
Other (please specify) Not working

21

Column

What systems are in place to support and confirm that shared decision making has been implemented?

Objective data

Subjective data

Column

Your results

Options Objective
Care record audit
Using a questionnaire/ tool to elicit people’s experiences (please specify which measure)
None Yes
Not relevant
Other (please specify)
Options Subjective
To what degree is this information fed back into practice? Not working

22

Column

How are caseloads assigned to the following teams?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Nursing specialists None
Mental health services None
Care providers (e.g. agency workers) None
Social workers None
Community therapy teams None
Other (please specify below) None None

23

Column

Are there ongoing efforts to ensure that support and training for staff in P3C continues to be developed in the following areas?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Person centeredness None
Self-management None
Empowering and activating individuals to be involved in self-care Yes Working well
Coordinating care across teams None
Health coaching None
Shared decision making None
Supporting health promoting behaviours None
Managing polypharmacy None
Decision making in multimorbidity None
Promoting managed risk taking for individuals None
Other (please specify)

24

Column

Which of the following activities/ resources are supporting culture change for P3C?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Change Champions for PCCC None
Formal benchmarking (eg reviewing performance indicators such as number of personalised care plans against internal performance or external organisations None
Informal benchmarking (eg group reflections on practice) Yes Working well
Auditing PCCC activities None
Other (please specify)

25

Column

What interventions are in place to reduce unplanned or inappropriate emergency admissions

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Predictive modelling to identify people most at risk Yes Working well
Support to increase self-management skills during crisis (e.g. medication/help seeking) Yes Working well
Telemedicine (providing remote clinical services to patients via communications technologies) Yes Working well
Hospital at home service (intensive community based treatment) None
Use of virtual ward None
Coordinated working between health and social care (e.g. joint assessments) None
Ward based health and social care coordinators to support discharge Not relevant
Individualised discharge plans Yes Requires some improvement
Implementation of specialist support Services e.g. intermediate/ complex care teams (please specify) None
Advanced planning (e.g. Treatment Escalation plans (TEP), Lasting Power of Attorney (LPA) Yes Requires some improvement
Community rehab/ therapy teams Yes Requires significant improvement
Open-Ended Response

26

Column

What procedures are in place to address polypharmacy/ review medication management?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Pharmacist attending MDT meeting No
Pharmacist review for some or all patients No
Questions/ prompts about medicine taking for patients during reviews No
Routine face to face medicine reviews Yes Requires significant improvement
Training for patients in medicine optimisation No
Medicine audit Yes Not working
Other (please specify)

27

Column

What other systems are in place to support P3C?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
The pooling of budgets to be used flexibly by teams None
Use of tools and care plans to identify missing pathways None
Measurement of staff experience of PCCC None
Paper based directory of services None
Other (please specify)

28

Column

What kind of promotion is there to support self-care?

Objective data

Subjective data

Column

Your results

Options Objective Subjective
Telecare No
Telemedicine No
Telecoaching No
Other (please specify)

29

Column

Which of the following IT based systems are in place?

Which of the following IT systems are in place?

Which of the following IT systems are in place?

Column

Subjective data

Column

Your results

Options Objective Subjective
A template/ record keeping system to bring together a single care plan within your team Yes Requires some improvement
A template/ record keeping system to bring together a single care plan which is shared across organisations Yes Requires significant improvement
Electronic health/ social care plans accessible across team boundaries in real time None
An electronic directory of services None
Individuals routinely have access to care plan/ records None
Individuals can add to their electronic care plan/ record None
Other (please specify) Requires significant improvement
Across team agreements to access people’s records Across some teams Requires significant improvement
Across team agreements to add to people’s records Across some teams Requires significant improvement
Across team agreements to inform others of changes to people’s records Across some teams