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Unit 20: Care Planning
Processes in Healthcare Practice
Session 9
• L04 Reflect upon the impact of the planning of care on practitioners,
individuals, family and carers in relation to own practice
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Effective Team working STEPPS
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Partnering With the Resident
Embrace residents as valuable and contributing partners in
their care
• Learn to listen to residents and their families
• Assess the resident’s preferences regarding involvement
• Ask residents about their concerns
• Speak to them in lay terms
• Ask for their feedback
• Give them access to relevant information
• Encourage residents and their families to proactively
participate in resident care
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5
Partnering With the Resident
Embrace residents as valuable and contributing partners in
their care
• Learn to listen to residents and their families
• Assess the resident’s preferences regarding involvement
• Ask residents about their concerns
• Speak to them in lay terms
• Ask for their feedback
• Give them access to relevant information
• Encourage residents and their families to proactively
participate in resident care
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Paradigm Shift to Team System
Approach
Dual focus (clinical and team skills)
Team performance
Informed decisionmaking
Clear understanding of teamwork
Managed workload
Sharing information
Mutual support
Team improvement
Team efficiency
Single focus (clinical skills)
Individual performance
Underinformed decisionmaking
Loose concept of teamwork
Unbalanced workload
Having information
Self-advocacy
Self-improvement
Individual efficiency
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Why Teamwork?
• Reduce clinical errors
• Improve resident outcomes
• Improve process outcomes
• Increase resident satisfaction
• Increase family satisfaction
• Increase staff satisfaction
• Reduce staff turnover
• Reduce resident and family grievances
and complaints
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High-Performing Teams
Teams that perform well:
• Hold shared mental models
• Have clear roles and responsibilities
• Have clear, valued, and shared vision
• Optimize resources
• Have strong team leadership
• Engage in a regular discipline of feedback
• Develop a strong sense of collective trust and confidence
• Create mechanisms to cooperate and coordinate
• Manage and optimize performance outcomes
(Salas, et al., 2004)
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Barriers to Team Performance
• Inconsistency in team
membership
• Lack of time
• Lack of information sharing
• Hierarchy
• Defensiveness
• Conventional thinking
• Varying communication styles
• Conflict
• Lack of coordination
and follow up
• Distractions
• Fatigue
• Workload
• Misinterpretation of cues
• Lack of role clarity
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Multi-Team System (MTS) for Resident Care
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Core Team
members have
the closest
contact with
the resident!
A Core Team is…
A group of care providers
who work interdependently
to manage a set of
assigned residents
from point of
assessment to
discharge
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A team comprising those
work area members who are
responsible for managing
the operational
environment that
supports the
Core Team
A Coordinating Team is…
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A time-limited team formed
for emergent or specific
events and composed
of members from
various teams
A Contingency Team is…
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Ancillary Services provide direct,
task-specific, time-limited care to
residents
Support Services provide indirect
service-focused tasks that help to
facilitate the optimal health care
experience for residents and their
families.
Ancillary and Support Services provide…
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• Establish and communicate
vision
• Develop policies and set
expectations for staff
related to teamwork
• Support and encourage
staff during implementation
and culture change
• Hold teams accountable
for team performance
• Define the culture of
the nursing home
The Role of Administration is to…
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Example: A Multi-Team System
in a Nursing Home
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Exercise: Your Multi-Team System
?
?
Integration, cooperation and partnership
working
• NHS Reorganisation Act 1973
• The New NHS: Modern, Dependable 1997
• Health Act 1999
• Independence Wellbeing and Choice 2005
• National Health Service Act 2006
• Health and Social Care Act 2012
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Importance of involving service users in
assessment and care planning
Access to services
Local provision
Prevent and delay care needs
Integration, cooperation, partnerships
Silo working Organisational
barriers
Different operational practices
Duplication
Vision and outcomes of Integration,
cooperation and partnership working
• “The vision is for integrated care
and support that is personcentred, tailored to the needs
and preferences of those
needing care and support, carers
and families.”
• Improve service user experience
• Eliminate duplication
• Streamline care pathways
• Collaborate on early intervention
and prevention
• Improve safeguarding
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Why integration, cooperation and
partnerships?
 Improves the service user experience
 Eliminates duplication
 Streamlines care pathways
 Early intervention and prevention
 Improves safeguarding
Teamwork and leadership
• processes and impact:
• Leading the care process
• Working in partnership Supporting care teams
• multidisciplinary approaches
• Promoting best practice in the best interests of the individual
• Reflective review, identifying gaps in service to improve
• Collecting and interpreting data and drawing conclusions
• Reviewing measures and terminating ineffective processes
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Why integration, cooperation and
partnerships?
• Improves the service user experience
• Eliminates duplication
• Streamlines care pathways
• Early intervention and prevention
• Improves safeguarding
What do we mean by integration,
cooperation and partnerships?
• Integration: The combined set of methods, processes and models that
seek to bring about improved coordination of care
• Cooperation: Public organisations working in partnership to ensure a
focus on the care and support and health and health-related needs of
their local population
• Partnership: A joint working arrangement where the partners: are
otherwise independent bodies; agree to co-operate to achieve a
common goal; create a new organisational structure or process to
achieve this goal; plan and implement a joint programme; share
information, risks and rewards
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Involving and working with families
• The vision is for integrated care and support that is person-centred,
tailored to the needs and preferences of those needing care and
support, carers and families.”
• Care and Support Statutory Guidance October 2014
Other legislation and policies
• This duty applies where the local authority considers that the integration of
services will:
• “promote the wellbeing of adults with care and support needs or of carers in its
area;”
• “contribute to the prevention or delay of the development by adults in its area of
needs for care and support or the development by carers in its area of needs for
support, or;”
• “improve the quality of care and support for adults, and of support for carers,
provided in its area (including the outcomes that are achieved from such
provision).”
• The Health and Social Care Act 2012 (Sections 13N and 14Z1) also states that the
NHS also has a duty to promote and secure integrated care where it will improve
the quality of services, and reduce inequalities in accessing services or improve
outcomes.
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The five aims of cooperation
• Promoting wellbeing
• Improving the quality of care (including the outcomes from such
provision)
• Smoothing the transition from children’s to adults’ services
• Ensuring agencies work effectively together to safeguard adults at risk
of abuse or neglect
• Reviewing and learning lessons from cases where adults have
experienced abuse or neglect
Integration, cooperation and partnership in
practice
 Partnership, cooperation and integration need to be key components
of a local authority’s strategic approach. This may be with a range of
organisations (including other local authority functions, public sector
organisations and the independent and private sector) and occur in a
number of ways:
• Planning and commissioning
• Assessment and information
• Care delivery
• Quality assurance
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• Strategic planning by building better commissioning arrangements or
joint commissioning teams
• Commissioning integrated services, or jointly commissioning specific
services such as advice and advocacy services
• Assessments, information and advice such as integrated health, care
and housing assessments
• Delivery or provision of care via integrated community teams, or
working with housing providers to ensure that adaptations support
independence, reablement or recovery
• Working together: examples of integration, cooperation and
partnerships
 Joint information and advice service – based around the needs of the
end user rather than around individual services or structures
 Integrated assessment processes
 “Care co-ordinators”
 Integrating assessment and care planning for carers
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Supervision and management:
• Review of practice, review of policies Measuring outcomes, data
analysis Quality assurance, meeting regulatory standards,
benchmarking.