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Description
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Enables the maintenance of a single, shared care plan across multiple Organisations to ensure more co-ordinated working and more efficient management of activities relating to the Patient/Service User's health and care. |
Shared Care Plans support a Patient-centred approach to care. It allows Health and Care Professionals to view and maintain a single, shared Plan for the Patient/Service User rather than holding separate and disconnected Plans within the individual health and care organisations. It encourages a collaborative approach to supporting Patients/Service Users to meet their health and care needs, including Patients/Service Users with long-term conditions or in residential care. Health or Care Professionals with appropriate access rights involved in delivering care for the Patient/Service User can see and contribute to a Patient/Service User's Care Plan. Guardians, Caregivers with appropriate access rights or the Patient/Service User can also view and update them.
In integrated care settings, all members of the Care Team should have access to the same information and can build upon the Shared Care Plan. Team members act in coordination towards a common goal to provide integrated care and avoid errors. A Shared Care Plan functions as a living document that members of the Care Team refer to or update on an ongoing basis. Service Providers must also be able to seamlessly share and access Shared Care Plans across health or care settings that use different IT systems.
Examples of Care Plans include:
- End of Life Care - contains a Patient/Service User's preferences and wishes for their end of life care
- Urgent Care Plan - contains a Patient/Service User's preferences and wishes in an urgent care setting
- Transitional Care - contains anticipated changes in a Patient/Service User's health status, helping them manage key transition periods in their lives and their care trajectory
- Advanced Care Plan - Following a discussion with the individual about their future wishes and priorities regarding the type of care they would wish to receive and where they wish to be cared for, the plan may be enacted if they lose capacity or are unable to express a preference in the future
- Escalation Plan - contains the support the Patient/Service User would receive in managing potential future events relating to their condition(s). It may cover what to do when Patient/Service User's condition deteriorates and may include instructions for emergency care professionals (e.g. paramedics)
Outcomes
| Patient/Service User |
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| Care Team (Care Coordinator, nurses, health professionals, Carer (family or friend), GP) |
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| Other Organisations (e.g. NHS111, Hospitals, Community Service Providers, Schools). |
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| Family members, friends and other Carers |
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EpicSC1 C36E1 - create Shared Care PlanAs a Care Team Member I want to be able to create Shared Care Plans So that I can collaborate with other Care Team Members in delivering care to a Patient/Service User Acceptance criterion 1: Care Team Member creates a Shared Care Plan for the Patient/Service UserGiven that the Patient/Service User has been assessed as 'in need of planned care' And the Care Team Member is permitted to create Shared Care Plans When the need for a Shared Care Plan is identified for a Patient/Service User Then the Care Team Member can create a Shared Care Plan for the Patient/Service User And they can record information relating to the Shared Care Plan And the Care Plan can be shared with other Care Team Members EpicSC2C36E2 - view Shared Care PlanAs a Care Team Member I want to be able to view the Shared Care Plan for a Patient/Service User So that I can understand the Patient/Service User's Plan and use it to deliver the right care Acceptance criterion 1: Care Team Member views a Shared Care Plan for the Patient/Service UserGiven that the Patient/Service User’s Shared Care Plan has been defined And the Care Team Member is permitted to view Shared Care Plans When the Care Team Member wants to view the plan for the Patient/Service User Then the Shared Care Plan for the Patient/Service User is displayed EpicSC3C36E3 - amend Shared Care PlanAs a Care Team Member I want to be able to amend Shared Care Plans So that progress against the Shared Care Plan can be tracked and the Shared Care Plan can be updated to align to any change in needs of the Patient/Service User Acceptance criterion 1: Shared Care Plan is amended by a Care Team Member or Patient/Service UserGiven that the Patient/Service User’s Shared Care Plan has been defined And the Care Team Member is permitted to amend Shared Care Plans When a change to the Shared Care Plan is agreed with the Patient/Service User Then the Shared Care Plan can be amended EpicSC4C36E4 - close Shared Care PlanAs a Care Team Member I want to be able to close a Shared Care Plan when it is no longer needed So that I have an accurate view of active and inactive Shared Care Plans Acceptance criterion 1: Care Team Member closes the Shared Care PlanGiven that the Patient/Service User’s Shared Care Plan has been defined And the Care Team Member is permitted to close Shared Care Plans When it is identified that the Shared Care Plan is no longer needed (e.g. desired outcomes have been achieved or the Patient/Service User no longer needs support) Then the Shared Care Plan can be closed or made inactive |
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EpicSC5 C36E5 - assign Shared Care Plan actionsAs a Care Team Member I want to be able to assign actions to a member of the Care Team, the Patient/Service User or their Carer and monitor progress So that I can track progress against the Shared Care Plan and ensure the outcomes are achieved Acceptance criterion 1: assign action to Care Team Member, Patient/Service User or CarerGiven that the Patient/Service User’s Shared Care Plan has been defined When an action needs to be assigned to support delivery of the Shared Care Plan for a Patient/Service User Then actions can be assigned to a member of the Care Team or the Patient/Service User And progress on actions can be captured or recorded And progress can be tracked EpicSC6C36E6 - access Shared Care Plans remotelyAs a Care Team Member I want to be able to access and update Shared Care Plans when I am away from my workstation (e.g. during field visits) So that I can improve productivity by being able to maintain the Shared Care Plan even when I am working remotely Acceptance criterion 1: Care Team Members can view and update the Shared Care Plan during field visitsGiven that there is a Shared Care Plan for the Patient/Service User When the Care Team Members is working remotely (e.g. on field visits) Then they can view the Shared Care Plan And any updates to the Shared Care Plan can be made EpicSC7C36E7 - search and view Shared Care PlansAs a Care Team Member I want to be able to search for the Shared Care Plan for Patients/Service Users using search criteria So that I can access the relevant Shared Care Plan details Acceptance criterion 1: Care Team Member searches for and views Shared Care PlansGiven Shared Care Plans have been set up for Patients/Service Users When criteria (e.g. Patient/Service User name, type of plan) are used to search for Patients/Service Users or their Shared Care Plans Then a list of records that match the criteria is displayed And one or more Shared Care Plans can be selected to be viewed EpicSC8C36E8 - real-time access to Shared Care PlansAs a Care Team Member I want to have continuous access to the current version of a Shared Care Plan within its availability target (e.g. 24x7 and 365 days per year) So that I can make informed decisions for the Patient/Service User based on the most up-to-date information available in the Shared Care Plan Acceptance criterion 1: Shared Care Plans availabilityGiven that there is a Shared Care Plan for the Patient/Service User When the Shared Care Plan is accessed within its availability target period Then the Shared Care Plan is available to view and / or update EpicSC9C36E9 - notificationsAs a Care Team Member, Patient/Service User or other person who has access to a Shared Care Plan I want to be able to send and receive notifications in relation to a Shared Care Plan So that I can ensure that everyone who is involved in the health or care of the Patient/Service User is kept up to date with any changes to the Shared Care Plan Acceptance criterion 1: send message in relation to Shared Care PlanGiven that the Care Team Member(s), Patient/Service User or other has authorised access to the Shared Care Plan Solution When they need to communicate with another Care Team Member, the Patient/Service User or their Carer in relation to a Shared Care Plan Then a message or notification can be sent to one or more recipients And the message can be read only by the intended recipient(s) Acceptance criterion 2: receive message in relation to Shared Care PlanGiven that the Care Team Member(s), Patient/Service User or other has authorised access to the Shared Care Plan Solution When a message or notification is received relating to the Shared Care Plan (e.g. action assigned or change to the Plan) Then they receive a message or notification And they can view the message or notification EpicSC10C36E10 - reportsAs a Care Team Member I want to have access to custom reports relating to the Shared Care Plans for my Patients/Service Users So that I can use the information to plan my work better Acceptance criterion 1: Care Team Member views reportsGiven that the Care Team Member(s) has access to the Shared Care Plans for one or more Patients/Service Users And the Care Team Member has access to run reports When the Care Team Members wants to report on information relating to Shared Care Plans Then a report can be run to create the relevant output relating to Shared Care Plans EpicSC11C36E11 - manage Shared Care Plan templatesAs a Care Team Member I want to be able to maintain Shared Care Plan templates or utilise preloaded Shared Care Plan templates So that I can improve efficiency by using existing templates to create Shared Care Plans Acceptance criterion 1: Use preloaded Shared Care Plan templatesGiven that the Care Team Members have authorised access to the Shared Care Plan Solution When they want to use a Shared Care Plan template to create a Shared Care Plan for a Patient/Service User Then they can access an existing template And use the template to create the Shared Care Plan for the Patient/Service User Acceptance criterion 2: maintain Shared Care Plan templatesGiven that a Care Team Member has authorised access to maintain templates in the Shared Care Plan Solution When a change is required relating to a Shared Care Plan template Then the Care Team Member can create, update or delete the relevant Shared Care Plan template EpicSC12C36E12 - manage care schedulesAs a Care Team Member I want to be able to manage my care schedule So that I can plan my upcoming Patient/Service User visits and actions relating to their Shared Care Plan Acceptance criterion 1: Care Team Member manages care schedulesGiven that a Care Team Member has authorised access to the Shared Care Plan Solution When they need a new or updated care schedule Then they can create or update a care schedule And information can be recorded about the planned visit(s) And the schedule can be shared with other Care Team members and Patients/Service Users as appropriate |
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Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability: None |
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Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability: |
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Suppliers will not be assessed or assured on these Roadmap Items as part of Onboarding
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