Unit 3: Supporting the Individual Journey through Integrated Health and Social Care

Introduction

The integration of the Health and Social Care sub-sectors is important in terms of being able to provide services for the wellbeing of individuals, and to meet the increasing demands of a growing and ageing population with increasingly complex needs. Students working in health will need to be aware of integrated care pathways: a multidisciplinary approach towards anticipated care that enables an individual with identified needs to move progressively through their journey and experience positive outcomes. The aim of this unit is to develop students’ understanding of an individual’s right to being involved in their own care and develop students’ skills in promoting this right when working with individuals. This right is, in many cases, enshrined in law and in the fundamental standards of care. It is a critical element of person-centred care and leads to improve and often more cost-effective outcomes. Students will explore the importance of working relationships within multidisciplinary settings and the impact on the individual.

Learning Outcomes

By the end of this unit students will be able to:

  1. Examine the health, care and support services available to an individual requiring multidisciplinary care
  2. Assess an individual’s capacity to identify their own needs
  3. Describe the impact of own relationship with the individual and multidisciplinary teams involved in the delivery of the care pathway
  4. Demonstrate the need for person-centred communication in implementing person-centred plans.

Essential content

LO1 Examine the health, care and support services available to an individual requiring multidisciplinary care

Definitions of and differences between key concepts: Health/healthcare service providers (organisations and institutions) Social care service providers (organisations and institutions) Support service providers (organisations and institutions) Care provision (the type of care provided within and between organisations) Integrated care Multidisciplinary care Co-production

Partnership working Holistic care Agreed ways of working Local health, care and support service provision across a range of differing organisations: How different organisations meet different needs of an individual Recognising that services provided by organisations can serve a wide population, e.g. the service provided by hospices focus on quality of life at different ages and stages of life, the availability of their service is not determined by the age of the individual Differences in professional practice in different local organisations: Challenges faced by organisations in working with others to provide care for an individual Impact on the individual’s journey through integrated care Local unmet need and the reasons this occurs: e.g. issues with rural supply and demand, other social and economic determinants – poverty, geography Wider community resources available to support an individual’s care needs: In the voluntary, independent and private sector, e.g. public services

LO2 Assess an individual’s capacity to identify their own needs to promote holistic person-centred care

Principles of mental capacity and establishing consent Self-directed and service support The strength based approach in the Care Act (2014) and its relevance in care planning Advantages and disadvantages of care pathways for vulnerable people Innovative integrated health and social care initiatives or projects that could be used to meet local unmet need Differences in existing assessment planning, implementation and review processes Professional accountability within safeguarding policies and procedure Features of person-centred approaches to integrated care: Working in a person-centred way to promote an individual’s wellbeing Respecting and valuing diversity Own contribution to identifying an individual’s needs in the care pathway Taking an individual’s privacy and dignity into account when planning and providing care Supporting inclusive practices and enabling the individual to make choices and actively participate in their own care

LO3 Describe the impact of own relationship with the individual and multidisciplinary teams involved in the delivery of the care pathway

Influencing skills in decision-making processes: Benefits of networking with the individual and multidisciplinary teams for the individual receiving services or care: for self for the teams involved in care provision for the organization Information sharing to support the best outcomes for the individual Reporting and recording safeguarding issues while working in a multidisciplinary setting Purpose and methods Confidentiality, safety and security Features of effective partnership working: Processes and research that can inform decision-making Systems and processes that support an individual through the integrated care pathway Enablement skills used by services to support individuals to meet their needs Responsibilities in the integrated pathway relationships Effective transfers of care Structure and functions of multidisciplinary teams: Purposes Services involved Team members and how they adopt an empathic approach with individuals Person-centred holistic approach which clearly focuses on duty of care and treating individuals with dignity, respecting their beliefs, culture, values and preferences Facilitating relationships within a multidisciplinary setting to create safe environments where all involved have the courage to challenge areas of concern and work to best practise can be demonstrated

LO4 Demonstrate the need for person-centred communication in implementing person-centred plans

Key features of person-centred planning: Support an individual to balance their rights and choices with delivering duty of care, recognising the individual as an equal partner Empowering the individual to report their changing needs within the integrated care pathway Knowledge and inter-personal skills required to implement person-centred plans: Promoting a commitment to ensuring a balanced approach to positive risk taking Flexible advocacy provision as people use different services Supporting an individual to raise concerns regarding the ongoing delivery of their care and using appropriate channels of support Ensuring own professional values encompass the care values, e.g. care, compassion, courage, communication, commitment and competence Differences between informal and formal communication Adapting communication according to the needs of the individual, e.g. ensuring an individual’s disability is taken into account when selecting and using different forms of communication Respecting the need for privacy and dignity when communicating with individuals accessing services Duty of candour and own personal role in being transparent and honest Being adaptable and conscientious in trying to balance an individual’s rights and choices for empowerment and autonomy with duty of care and carers’ expectations

LO1 Examine the health, care and support services available to an individual requiring multidisciplinary care

P1 Outline local resources and provision that supports integrated care working

P2 Describe current local unmet need related to health, care and support service provision in own locale

M1 Explain the difference between healthcare and social care providers and types of interagency care provision in relation to meeting the needs of the individual requiring care

D1 Evaluate local resources and provision in terms of meeting the needs of an identified individual requiring multidisciplinary care

LO2 Assess an individual’s capacity to identify their own needs

P3 Provide support to an individual in a health, care or support service setting towards the identification of their own care needs

P4 Describe the role of the health, care or support service practitioner in supporting person-centred care

M2 Explain own involvement in the different person-centred assessments used to define an individual’s care pathway

D2 Evaluate the differences in care assessments across the integrated care pathway

LO3 Describe the impact of own relationship with the individual and multidisciplinary team members involved in the delivery of the care pathway

P5 Provide appropriate leadership within the remit of own role in a health, care or support service to promote effective interprofessional and multidisciplinary team working

P6 Describe the responsibilities of information sharing between multidisciplinary teams

M3 Provide competent and autonomous leadership in information sharing within a multidisciplinary team in own setting towards meeting different individuals’ care needs

D3 Provide a detailed analysis of own personal growth and development in supporting an individual to access the quality integrated care they require to meet their needs, within parameters of own practice