Care planning is an important approach for making sure that individuals receive joined-up care and personalised support. NHS England has created a handbook that presents care planning as a four-stage process: prepare, discuss, document and review.

In the second of a series of summer webinars, Bruce Horne, product specialist lead, outlined how Orion Health sees this working.

Care planning is about “planning and agreeing how someone’s health and social care needs can be met,” he said, and once that’s done it’s about “documenting that care in a way that professionals, service users and families can share” as required.

What is care planning, and why use the shared care record?

Care planning is a national priority. It was a feature of the NHS Long Term Plan, published in 2018, and has been promoted by NHS England as a key use-case for information sharing. There has been a particular focus on recording end of life wishes to avoid unnecessary hospital admissions or unwanted treatment.

And organisations like the Professional Records Standards Body have been working on standards for what information should be captured and how it should be displayed. Yet different areas of the country and different organisations within one area may be taking different approaches and using different IT systems to support this activity.

So, Horne asked, why should areas be looking to use their shared care record? Many reasons, he suggested. First, this aligns with national policy: NHS England has made care planning an important and early feature of its roadmap for developing shared care records over the next two or three years.

Second, on the ground, the people who are going to be involved in care planning are going to be the people who use or need a shared care record. “Care planning is collaborative by nature,” Horne pointed out. “There are multiple people who need to contribute to a care plan, the shared care plan is an ideal platform from which to promote the kind of multi-disciplinary working required.”

Indeed, using the shared care record stops new silos from forming, as different teams use different IT systems to create and store care plans. A final benefit, Horne added, “using the shared care record for care planning helps to enrich the shared data sets within the shared care record and make them more valuable for users.”

How does Orion Health’s standardised, framework design approach help?  

As a leading provider of shared care records to health and care organisations, Orion Health has created a maturity model that moves customers from “viewing” aggregated data to “doing” point of care and analytics with it. To support this “doing” activity, it has been creating solutions with a consistent look and feel, so it is easy to re-use functionality for specific use cases, from care planning to other priorities such as virtual wards.

Horne outlined some of the benefits of the “framework design” approach. The big benefit, he argued, is that solutions will be “standardised for all customers in the UK, wherever they are” (with some scope for variation to meet local needs). They will also reflect best practice – including the PRSB standards – which will make it easier for Orion Health to deploy, maintain and support collaboration between customers.

Orion Health has a set of “components” that include the Amadeus platform that aggregates data from many different systems and the shared care record itself. Working up from these foundations, elements of the Coordinate suite can be used in different use cases; for example, ‘Care Pathways’ can be used to drive the logic of which forms are presented to care planners and when.

The Orion Health ‘forms’ have been created “to have a good user interface, and to be flexible enough to work in different use cases” while ‘Collaborative Worklists’ can be used to show teams what forms have been completed for patients in their care and to give them access to their information. Orion Health Discover can be used to surface and analyse data. The Orion Health Engage portal can be used to enable patients, their families and carers to access and review their own care plans.

Horne flagged that an increasingly important element of Engage is ‘About Me’, which also complies with a PRSB standard. This enables patients, families and carers to record information that is important to the individual – whether that’s who to call in an emergency, or how to care for a pet.

What does this look like for different use cases?  

In the main body of the webinar, Horne explained how these components have been put together in specific use cases. He demonstrated how to enrol a patient on an end of life care plan, and how enrolment opens up the relevant forms, which can be populated using a variety of free text, radio buttons, and other features.

The forms can be viewed on a dashboard that makes it easy for professionals to see if the form has been completed and a patient’s DNR status. He also demonstrated how other dashboards, such as those for lab results, can be used to compile lists of patients who might benefit from the care planning approach.

Similarly, Horne showed how Connecting Care was able to build a ‘transfer of care’ pathway during the Covid-19 pandemic by using the components. Enrolment triggered a form that could be accessed by all the professionals involved in the transfer until the patient was safely ‘discharged’ into the community.

In addition, he showed how New Zealand customer, Southern Cross, was able to build a pre-admission pathway. Patients are enrolled to trigger a form that includes a status bar to show how much of the pre-admission process has been completed.

He demonstrated how the same thinking is being applied to virtual wards. Again, patients are enrolled to trigger a monitoring form that can be completed on a rolling basis, with information viewed through a dashboard or patient lists, until the patient is ready to be discharged from the ward.

How fast can we get started?

Horne stated that Connecting Care had been able to create its transfer of Care Pathway in seven weeks. That was the main question that the webinar audience wanted to ask: just how fast can this be done?

His answer: it will depend on the use case and on how ready local professionals are to engage. “The standard framework is Orion Health’s attempt to support the process,” he said. “But at the local level, ensuring you have an aligned, engaged stakeholder group is key. If you have that in place, then it is possible to make very timely progress.”

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