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Full ResultsColumn
What do you do to ensure that a person doesn’t have to repeat themselves unnecessarily?
Objective data
Subjective data
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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 | Yes | Requires some improvement |
| A shared care plan document within your team | Yes | Working well |
| A shared care plan document across teams | Yes | Requires some improvement |
| MDT / Clinical meetings | Yes | Requires some improvement |
| Discharge planning | Yes | Requires some improvement |
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Which of these is available to empower people?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Providing information sheets | Yes | Working well |
| Signposting to the 3rd sector | Yes | Requires some improvement |
| Referrals to other services | Yes | Requires some improvement |
| Referrals to peer support groups | Yes | Working well |
| Pharmaceutical support | Yes | Requires significant improvement |
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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
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Your results
| Options | Objective |
|---|---|
| Within teams | All |
| Across teams | All |
| If no, why not? | |
| Are they given a copy of there care plan? | Yes |
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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
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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 | |
| Treatment Escalation Plan | Yes |
| None | |
| Not relevant |
| Options | Subjective |
|---|---|
| How well are your care plans working? | Working well |
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Who normally takes the lead for care planning/ care coordination?
Objective data
Subjective data
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Your results
| Options | Objective |
|---|---|
| Managerial lead | Yes |
| Clinical lead | |
| Team coordinator | |
| GP | Yes |
| District/ Community Nurse | |
| Community Matron | |
| Community Therapy teams | |
| Social workers | |
| Care workers | |
| None | |
| Not relevant | |
| Other, please specity: | IT lead - informing GPs of those people, whose care plan needs updating - Practice manager will prepare documents for monthly reviews |
| Options | Subjective |
|---|---|
| How well is this working? | Requires some improvement |
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How is shared decision making with individuals supported in your organisation?
Objective data
Subjective data
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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 | |
| Personal budgets | |
| None | |
| Not relevant | |
| Other (please specify) | decisions on CPR - hospital admission - care needs - power of attorney |
| Options | Subjective |
|---|---|
| How well is shared decision making working in general in your organisation? | Working well |
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How do practitioners specifically elicit goals related to people’s health and social aims?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Personalised care plans structured around the identification of goals | Yes | |
| Goals prompted in a separate section of the written personalised care plan | Yes | |
| Some practitioners trained to provide guided conversations | None | |
| Longer appointment times | None | |
| Using best interest (e.g. Power of Attorney or formal advocate) | Yes | |
| Other (please specify) |
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How do practitioners ensure that people are supported to achieve their individualised social goals?
Objective data
Subjective data
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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
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How is support tailored to the person’s ability and motivation to manage their own health?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Use of a patient measure of activation (e.g. PAM) | None | |
| 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 | Yes | Working well |
| Group based training for self-management | Yes | Requires some improvement |
| Disease specific training | Yes | Requires some improvement |
| Other (please specify) |
9b
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How are self-management scores (e.g. PAM) fed back into practice?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Gathered externally and never included in records | None | |
| Gathered externally and included in records but rarely used | None | |
| Used informally in care planning | None | |
| Structured within the care plan | None | |
| Other (please specify) |
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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
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Through Longer appointment times | Yes | Requires some improvement |
| Personalised care plans structured to address this | Yes | Working well |
| Mental health workers link into the team | None | |
| Other (please specify) |
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How are informal carers assessed and offered support?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Identification of the carer population | Yes | Working well |
| Carer health and wellbeing assessment | Yes | Requires some improvement |
| Providing advice and signposting to support services | Yes | Working very well |
| Provision of respite if required | Yes | Working well |
| Other (please specify) |
12
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With what other teams do you have agreements in place to enable partnership working and provide joined up care?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Community based hub or team specialising in LTCs | ||
| General practice | Yes | Working very well |
| Nursing specialists (e.g. District/ Nurses/ Community Matrons) | Yes | Requires some improvement |
| Mental Health services | Yes | Requires some improvement |
| Community Therapy teams | ||
| Paid care providers (e.g. care agencies) | Yes | Working well |
| Voluntary sector providers | Yes | |
| Social Work teams | Yes | Requires some improvement |
| Emergency Department | ||
| Community based admission avoidance teams | ||
| Intermediate care team | ||
| Residential/ care home providers | Yes | Working well |
| Other (please specify) | We are in the process of joining the hub locally, but so far this has not worked. |
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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?
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Subjective data
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Your results
| Options | Objective |
|---|---|
| Do multi-disciplinary team meetings take place? | Yes |
| General practitioners | Yes |
| Practice nurses | Yes |
| District nurses/ Community Matrons | Yes |
| 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 |
| Options | Subjective |
|---|---|
| How often do these MDT meetings happen? | Monthly |
| Other (please specify) |
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Are processes in place to allocate roles and responsibilities across and within teams?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Are processes in place to allocate roles and responsibilities across and within teams? | Yes | |
| Processes in place for a single named person coordinating the support and care of each person suitable for PCCC WITHIN teams | Yes | Working very well |
| Processes in place for a single named person coordinating the support and care of each person suitable for PCCC ACROSS teams | Yes | Working well |
| 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
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Which practitioners act according to the personalised care plan?
Objective data
Subjective data
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Your results
| Options | Objective |
|---|---|
| GP | Yes |
| District/ Community Nurse | Yes |
| Community Matron | |
| Mental Health Team | |
| Social Workers | |
| Care workers (e.g. agency workers) | Yes |
| Nominated 3rd sector providers | Yes |
| Physiotherapists | |
| Occupational therapists | |
| Consultant Specialists | |
| Other (please specify) | |
| Plans are used but not personalised | |
| Plans are not used | |
| Not relevant | |
| Other (please specify) | care homes - nurses and carers |
| Options | Subjective |
|---|---|
| How well is this working? | Requires some improvement |
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How do you provide proactive case management (identification, assessment, planning, monitoring and coordination)?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Use of predictive models to identify who will benefit from PCCC | Yes | Working well |
| Appointments are available for crisis care | Yes | Working well |
| Appointments are available for proactive care | Yes | Working well |
| Multi- Disciplinary Team (MDT) meetings to discuss complex cases | No | |
| Systematic review of caseload/ list | ||
| Allocation of an individual from MDT with responsibility to ensure ongoing care | No | |
| Other (please specify) |
17
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For which groups do you measure the experience of care:
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| People suitable for PCCC | None | |
| Families of individuals suitable for PCCC | None | |
| Carers of individuals suitable for PCCC | None | |
| Other (please specify) | Requires significant improvement |
| Use | Response |
|---|---|
| How do you use the measures from Q17a to inform the delivery of care/ support? |
|
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What systems are in place to identify and allocate people suitable for P3C?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Risk stratification and automatic allocation | None | |
| Risk stratification and allocation by team agreement | Yes | Working well |
| Agreement by team providing PCCC | Yes | Working well |
| Routine discharge screening | Yes | Working well |
| Ad hoc clinical complexity identified by practitioner | Yes | Requires some improvement |
| External practitioners/services refer in | None | |
| Other (please specify) |
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Which approaches are used to organise the care of those identified for P3C?
Objective data
Subjective data
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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 | Yes | Working well |
| MDT meetings | None | |
| Regular review of case load allocation | Yes | Working well |
| Other (please specify) |
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What contact/ appointment arrangements are in place to support P3C?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Appointments specifically for PCCC planning | Yes | Requires some improvement |
| Longer appointments available on request for routine care | Yes | Requires some improvement |
| Home visits for PCCC planning | Yes | Working well |
| Other (please specify) |
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What systems are in place to support and confirm that shared decision making has been implemented?
Objective data
Subjective data
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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? | Requires some improvement |
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How are caseloads assigned to the following teams?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Nursing specialists | None | Requires significant improvement |
| Mental health services | None | Requires significant improvement |
| Care providers (e.g. agency workers) | None | Requires significant improvement |
| Social workers | None | Requires significant improvement |
| Community therapy teams | None | Requires significant improvement |
| Other (please specify below) |
23
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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
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Person centeredness | Yes | Working well |
| Self-management | Yes | Working well |
| Empowering and activating individuals to be involved in self-care | Yes | Working well |
| Coordinating care across teams | Yes | Requires some improvement |
| Health coaching | Yes | Requires some improvement |
| Shared decision making | Yes | Working well |
| Supporting health promoting behaviours | Yes | Working well |
| Managing polypharmacy | Yes | Working well |
| Decision making in multimorbidity | Yes | Requires some improvement |
| Promoting managed risk taking for individuals | Yes | Working well |
| Other (please specify) | in process of getting involved with Mendip Symphony - upskill staff and work more across the disciplines |
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Which of the following activities/ resources are supporting culture change for P3C?
Objective data
Subjective data
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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 | Yes | Working well |
| Informal benchmarking (eg group reflections on practice) | Yes | Working well |
| Auditing PCCC activities | None | |
| Other (please specify) |
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What interventions are in place to reduce unplanned or inappropriate emergency admissions
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Predictive modelling to identify people most at risk | None | |
| 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 | Requires some improvement |
| Hospital at home service (intensive community based treatment) | None | |
| Use of virtual ward | Yes | Working well |
| Coordinated working between health and social care (e.g. joint assessments) | Yes | Requires significant improvement |
| Ward based health and social care coordinators to support discharge | None | |
| Individualised discharge plans | Yes | Working well |
| 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 | Working well |
| Community rehab/ therapy teams | Yes | Working well |
| Open-Ended Response |
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What procedures are in place to address polypharmacy/ review medication management?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Pharmacist attending MDT meeting | No | |
| Pharmacist review for some or all patients | Yes | Working well |
| Questions/ prompts about medicine taking for patients during reviews | Yes | Working well |
| Routine face to face medicine reviews | Yes | Working well |
| Training for patients in medicine optimisation | No | |
| Medicine audit | No | |
| Other (please specify) |
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What other systems are in place to support P3C?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| The pooling of budgets to be used flexibly by teams | None | Not Working |
| Use of tools and care plans to identify missing pathways | None | Not Working |
| Measurement of staff experience of PCCC | None | Not Working |
| Paper based directory of services | None | Not Working |
| Other (please specify) | Not Working |
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What kind of promotion is there to support self-care?
Objective data
Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| Telecare | Yes | Requires some improvement |
| Telemedicine | Yes | Requires some improvement |
| Telecoaching | No | |
| Other (please specify) |
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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?
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Subjective data
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Your results
| Options | Objective | Subjective |
|---|---|---|
| A template/ record keeping system to bring together a single care plan within your team | Yes | Working very well |
| A template/ record keeping system to bring together a single care plan which is shared across organisations | Yes | Working very well |
| Electronic health/ social care plans accessible across team boundaries in real time | None | |
| An electronic directory of services | Yes | Working very well |
| Individuals routinely have access to care plan/ records | Yes | Working well |
| 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 | |
| Across team agreements to add to people’s records | None | Requires significant improvement |
| Across team agreements to inform others of changes to people’s records | Across some teams |