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Minimum Standards for Shared Care and Support Plan
Introduction
Care and support planning supports the transition from the identification of need by assessment to the timely and effective implementation of appropriate interventions. The assessment processes should identify the needs and then, in producing a Shared Care and Support Plan, the lead assessor/care manager should document any related interventions intended to address those needs. The minimum standards for the Shared Care and Support Plan reflect this relationship.
The aim of planning care is to ensure that the person's needs are addressed in appropriate and acceptable ways. This should take into account the needs identified through assessment processes and should involve consideration of the person's wishes for their care and their aspirations for the future particularly from a re-enablement perspective. Care and support planning allows the lead assessor/care manager the opportunity to consider all the options / opportunities available to address assessed needs and to document these in the Shared Care and Support Plan.
The Shared Care and Support plan provides a mechanism to record multi-agency interventions in relation to a variety of needs and resources. It should be general in scope with the facility to be augmented with specialist care plans e.g. an individual requiring rehabilitation may have several specialist, specific, goal setting care plans which outline discrete stages in the process of addressing a particular need. The Shared Care and Support Plan should draw together the combined needs and agreed interventions into one cohesive document which can be shared with all the professionals involved and with the person (and where appropriate, paid and unpaid carers.
An intervention/resource can be:
- a service e.g. meals on wheels, respite
- a piece of equipment e.g. handrail
- or a person based resource e.g. physiotherapy
It is recognised that more than one intervention/resource might be required to address a need and not all needs will be able to be fully addressed; a shared plan of care and support should reflect the interventions/resources identified to best meet the need, either partially or fully. Whenever possible the emphasis should be on enablement, with a rehabilitation and anticipatory focus.
The content of a completed shared care and support plan will reflect the complexity of need and interventions.
Where Information Standards are shown here the actual method used locally for incorporating the standard into local tools is flexible. Where Data Standards are shown the format and codes specified should be adopted to achieve compliance.
Summary of minimum standards for Shared Care and Support Plan
The minimum standards for shared care and support plan cover:
- identification of the lead professional
- each identified need
- for each need:
- the interventions required
- the objective of the interventions
- a coded list of interventions (tba)
- the standards also include various start and end dates:
- date plan agreed and end date
- planned date for review
- start and end date of each intervention
- reasons for 'end of intervention' and for 'end of Plan'
Data Items
At a minimum the following sub set of the Personal Details should be included in the Care and Support Plan.
Person Details
- Structured Name or Unstructured Name
- Person Birth Date
- Person Identification
- Address
- Lead Professional Details taken from Associated Professional
The data items above are detailed in the Minimum Standards for Personal Details Section (Pages 11 - 20) and are selected from the Social Care Data Standards Manual, version 2.0 (August 2005).
| Type of Standard |
|---|
Identified Need/s A need, which has been identified during the assessment process. Dependent on local vocabulary, needs maybe related to issues/problems/concerns etc. Local definitions of need should also consider disability and personal requirement needs. During the compliance review for SSA for All Adult Client Groups, Partnerships should have identified preferred language in relation to 'need' which will be non-service specific. E.g. - Maintaining Personal Hygiene
| Information Standard |
Intended Outcome/s of Intervention/s The desired outcome/s for the person by initiating an intervention. E.g. - Rehabilitation / re-enablement / independence
- Care / support
- Independence maintaining personal hygiene
| Information Standard |
Data Item | Description | Field Length | Format | Type of Standard |
|---|
Intervention/s (to address Identified Need) | The intervention/activity/resource required to address a need identified during the assessment process. An intervention might relate to a particular task, resource or behaviour. As well as describing the direct intervention, it might also relate to the requirement for further assessment. Therefore an intervention might be a referral for a specialist assessment. The identified intervention should reflect the assessor/care planner's ability to decide the resource which is best to address the need/s. Several interventions may meet one need or one intervention may address more than one need. Similarly there maybe instances where no suitable interventions can be identified to address needs Draft pick list - Social Stimulation / Activity
- Prompting
- Supervision Physical Assistance or doing tasks for the person
- Equipment and Adaptations
- Specialist Assessment
- Counselling
- Behaviour Management
- Person Advice / Training
- Carer Advice / Training
- Other
| 3 | Pick list to be developed? | Data Standard |
Resources to address Interventions Identified resources such as services, professionals, equipment considered appropriate to address the identified needs. It should be recognised that there may be more than one resource required to address a need or, conversely, no resources to adequately address needs. E.g. - Telecare
- Respite Care
- Occupational Therapy
| Information Standard (This could be selected from a pre-determined list such as CADS and presented as a Data standard) |
Data Item | Description | Field Length | Format | |
|---|
Date Shared Care and Support Plan Agreed | The date on which all contributors to the plan have agreed its content. This is an overall, generic date and is not specific to individual components of the plan. It is the date that needs and interventions are agreed and the date from which interventions is measured against. E.g. 01/05/2007 | 10 | CCYY-MM-DD | Data Standard |
End Date of Shared Care and Support Plan | The date on which it is decided the Shared Care and Support Plan is no longer required or has no current relevance. E.g. 01/10/2007 | 10 | CCYY-MM-DD | Data Standard |
Reason Shared Plan of Care and Support Ended A record of why the Shared Care and Support Plan has been ended. This may be due to the fact that the person has moved away, is deceased, or the case has been closed for a particular reason such as all objectives have been met. E.g. - All intended outcomes met
- Person moved away
- Person died
| Information Standard (This could be selected from a pre -determined list and presented as a Data standard) |
Data Item | Description | Field Length | Format | |
|---|
Anticipated / Planned Date of Shared Plan of Care and Support Review | The date on which it is intended to review the overall identified needs and interventions (as outlined in the shared care and support plan). This date would be no more than a year from the date the 'Date Shared Care and Support Plan Agreed'. E.g. 29/07/2007 | 10 | CCYY-MM-DD | Data Standard |
Data Item | Description | Field Length | Format | |
|---|
Start Date of Intervention | The date on which an intervention was initiated. This is different from the referred or the requested date as some resources / interventions will have a waiting time. Similarly the actual start sate might be agreed to coincide with other components of the care and support plan such as hospital discharge. E.g. 29/07/2007 | 10 | CCYY-MM-DD | Data Standard |
Data Item | Description | Field Length | Format | |
|---|
End Date of Intervention/s | The date on which an intervention or the need for that intervention ceased E.g. 13/06/2007 | 10 | CCYY-MM-DD | Data Standard |
Reason Intervention Ended An explanation of why a particular intervention ended. E.g. - Person refusal
- Need Status Changed
- All intended outcomes met
| Information Standard (This could be selected from a pre-determined list and be presented as a Data Item) |
Data Item | Description | Field Length | Format | |
|---|
Has the person been informed as to who is the single point of contact | Has the person been verbally informed/given written advice as to who is the single point of contact for co-ordinating the delivery of care and support? Yes/No | 1 | Character | Data Standard |
1. If the person has not been verbally informed/given written advice as to who is the single point of contact for co-ordinating the delivery of care and support provide details | Information Standard |
Has the unpaid carer been informed as to who is the single point of contact | Has the unpaid carer been verbally informed/given written advice as to who is the single point of contact for co-coordinating the delivery of care and support? Yes/No | 1 | Character | Data Standard |
2. If the unpaid carer has not been verbally informed/given written advice as to who is the single point of contact for co-ordinating the delivery of care and support provide details | Information Standard |
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