Leading change

The Adult Services Complex Case Management Team at Solent NHS Trust manages the complex needs of patients within their care. A nurse in the team has led the development and implementation of improved approaches towards care planning to increase patient engagement. The change has led to improvements in outcomes, experiences as well as use of resources locally.

Where to look

The Care Quality Commission (CQC) (2016) highlight the growing body of literature clearly demonstrating the significant benefit and importance of involving people in decisions about their care, including how that care is delivered to meet their care needs and wishes. This approach to care delivery has resulted in benefits such as:

• Improved knowledge of their condition and treatment options;
• Increased confidence to self-manage aspects of their own care;
• Increasing the likelihood of keeping to a chosen course of treatment and participating in monitoring and prevention programmes;
• Improved satisfaction with their care and chosen treatment;
• More accurate risk perceptions;
• Reduced length of hospital stay and readmission rates.

The CQC’s 2016 review however identified that people needing long-term care and support are the least likely to report being involved in decisions regarding their healthcare. This includes people with long-term conditions, young people (18 to 24 years) and the oldest age groups surveyed (over 75 years). For these groups, their involvement in decisions about care and treatment is not always well-coordinated when they move between hospital, primary care and care services. The CQC recommends personalised care plans written with people, for people, and with their wishes and preferences clearly identified and monitored is essential to high quality care provision.

Within Solent NHS Trust, the nursing leads identified a variation in care plans used (including documentation of Home Health Care Monitoring). There was also varying levels of patient engagement in establishing these plans. The leads recognised the need for standardising the approach, to ensure patients are actively involved in their care plans, in line with the evidence which suggests higher levels of engagement can improve their health outcomes.

What to change

The Complex Case Management Team is a nurse led service which supports individuals who have multiple comorbidities, often accompanied by frailty. Such symptomatology often leads to these individuals requiring social care support. The team, made up of Community Matrons, Community Case Managers and Support Workers, focuses on ensuring high quality, integrated health and social care is provided to localities with the most vulnerable individuals.

On review, the Case Manager identified that there was variety in care plans used across Community Nursing and Case Management Teams. The complexity of the Home Health Monitoring care plan resulted in length completion times. The plan included tools such as the National Early Warning Score, Pain Management tools and Medication Management Reviews. Other tools which were needed to individualise this plan were not readily available and had to be added by clinical staff. The existing care plans also included limited guidance for staff in terms of patient engagement and establishing the perspective of the person and their wishes. The Nursing Leads discussed their findings with the wider team to gather input and feedback regarding the changes they wanted to implement, including anticipated improvements in care delivery.

How to change

Working collaboratively with the Quality Improvement Team, the Complex Case Management Team worked alongside patients, ensuring they were embedded in all developments to enhance care plans. A full audit of current practice was undertaken, to pull out key themes, trends and areas for improvement. Patient representatives were asked to share feedback via a questionnaire to review goal setting within the care plans. This pooled their thoughts on what they regarded as important for each support worker visit. Following consultation with practitioners and patients, a newly devised care plan (the ‘New Home Health Monitoring Care Plan’) was developed and introduced into practice. The new plan includes areas such as:

• Consent;
• Clinical Observations;
• Pain;
• MUST (Malnutrition Universal Screening Tool);
• Waterlow score (risk for the development of a pressure sore);
• Medication review;
• Mental wellbeing;
• Patient safety.

The care plans are jargon free and use reduced, simplified wording co-designed with the patients making the plans easier to understand and more accessible for all.

Adding value

Better outcomes: The new care plan is more efficient. Staff now spend less time writing lengthy notes as care plans already cover the key themes identified by the patients. The care plans are personalised to meet the needs of each individual and constantly tailored. Such an approach is supporting staff to discuss and agree with the patient, a coordinated plan which is beginning to demonstrate outcome improvements. The streamlined approach is also impacting positively on assessments and referrals which is also enhancing high quality patient care from the outset. A review post-implementation suggests every care plan now takes a personalised approach (100%). This is an increase from 40% before the changes. The baseline audit also measured ‘comprehensive completion’ of the elements in the care plan. This score has increased from 28% compliant to 100%.

Better experience: Patients report they now feel increasingly empowered to be engaged in the discussions and decisions regarding their health and care. There are also anecdotal reports of improved partnerships and rapport between professionals and patients.

Better use of resources: The enhanced approach to care plan use, engagement with patients, and streamlining of information gathering as a result is supporting staff in care delivery. For example, it is already improving communication between services such as hospitals and social care staff.

Challenges and lessons learnt for implementation

Quality Improvement is a combination of making a change and following a method to achieve a better measureable outcome. Involving the patient in that change was essential; full engagement in designing the care that they receive.

It is important to ensure adequate time is allocated to support change and do not overcomplicate things too early. It is also essential to ensure staff and patients are engaged from the beginning.

Successes have resulted in Solent NHS Trust Southampton Central Case Management Team now rolling out the new Care Plan Template to both East and West localities in Southampton.

Find out more

For more information contact:

• Rosalynn Lankford, Nurse Case Manager, Complex Case Team, Solent NHS Trust, rosalynn.lankford@solent.nhs.uk
• Kate Long, Senior Improvement and Engagement Facilitator, Quality Imrovement Team, Solent NHS Trust, kate.long@solent.nhs.uk