Change management and re-engineering the care plan in health and social care

The South & East Belfast Health & Social Services NHS Trust (SEBT) in Northern Ireland provide the full range of primary, secondary and tertiary mental health services, all community health services and social care programmes for all groups of vulnerable people. These include mental health, learning disability, physical disability, older people and children’s services.

SEBT was the first NHS organisation to create an integrated care record and has been a development partner with in4tek for Paris, originating with the Ithaca project, a European Telematics Research and Development initiative involving nine countries. The trust's achievements were recognised in the Healthcare IT Effectiveness Awards - see picture above

The system is being rolled out to replace stand-alone health and social care systems. Covering in excess of 20 different service areas, over 1000 staff now uses Paris as their main patient/client record, with over 120,000 patients registered. They were also the first authority to implement Paris Mobile. Full service implementation with all functionality is expected by December 2006.

Supporting information governance

Paris is an electronic information system that supports professionals working within a health and, or social services organisation to put information they collect in order and to share that information in a pre-arranged format and with pre-agreed colleagues. In so doing, it also supports information governance within the organisation. By bringing the risks and alerts together professionals are getting the total picture of a person and the information or care plan can be shared in an appropriate way.

The core elements of the Paris system developed and implemented at SEBT include: registration, referral, assessment, care planning, activity, review and discharge. Further tools provided include diary scheduling, stock and consumable ordering, linked through care planning.

Dr Gillian Rankin, director of service development at SEBT said, “The care plan is traditionally talked about as an ‘holistic care plan’ but when you scratch the surface the holistic care plan is the nursing care plan, it is the social work care plan or the physiotherapy care plan, it actually is not the ‘person’s’ care plan; because it doesn’t bring together all the separate components of care. What Paris does is to bring all that together visually as an integrated care package for that individual. In other words, the home help is not trying to visit at the same time the person is due at the clinic for a podiatry appointment.

“This is not an unusual occurrence and can be avoided by planning, done by the professionals and visually demonstrated in the system so that they can see that this is the person’s record. And, of course, it can then be streamlined for the person themselves. It is a case of change management and re-engineering.”

Separate assessments in ‘information silos’

In the delivery of community health and social care SEBT inherited a fragmented system whereby separate professional groups were doing separate assessments and recording that information in silos so it was not often seen or shared with other professional groups. Paris exposed that in a way that allowed the organisation to work with staff to do re-engineering.

“Everything stems from those kinds of concepts,” Gillian commented. “Re-engineering is actually engaging the staff from different professional groups to sit down and consider the value of sharing information, because it is only when that information is shared that the significant duplication that there is in the system becomes apparent. Let’s take the example of an mobility assessment; you will have the physiotherapist, the OT and the district nurse all doing different kinds of mobility assessment, but all trying to get broader information.

“Wouldn’t it be much better if we had a single agreed module of a mobility assessment, which any one of those three could use? And, once it’s on the system then there is a referral by a GP to the other service, they can piggyback, they can look at the information that’s already in the system and know that they don’t have to repeat that unless they need to update it or clarify something, or to do a more detailed assessment of some aspect of it.”

Some of the benefits were predicted and some were not according to Gillian, because the system is so intuitive and easy to use that the staff have identified benefits which SEBT would not necessarily have identified. She said, “Clearly one of the major benefits is that once a referral is received into the organisation, whether it is phoned in or electronically e-mailed in, it is then put onto the system by the call management centre or clerical staff, instantaneously. That information, that referral is then on the system for a professional member of staff.”

There is no delay of faxing or putting in the internal post, no waste of time. In the past SEBT have experienced severe backlogs, for example, podiatry referrals into the old system taking many days, plus the paper mountain. But it was quite normal to have a backlog of between five and ten days using paper referrals. Now they have re-engineered, through the call management centre, the referral data sets, which are all determined before implementing Paris. On receipt of the referral it is put straight onto the system, drastically shortening waiting times and freeing up professional time.

Designed for professionals to use directly

Paris is primarily a system that is accessible and is designed for professionals themselves to use, to record directly onto the system. This means you don’t need to have data clerks, giving a much greater degree of professional ownership of data quality and opportunities to streamline the care through a shared care plan.

Gillian has found the system excels in gathering multidisciplinary assessment (MA) and case study management. “With MA, if it’s on a manual system the task of gathering separate paper assessments put together by different professionals; sometimes in hospitals and sometimes in the community, can be a two week job,” she said. “Because all the assessments are in the Paris system those can all be collated in a very short space of time, normally two hours.” So again you are shortening length of stay in hospital or shortening the decision making time because information can be gathered more expertly.

“In caseload management,” Gillian added, “you can see at a glance what your staff are dealing with and the numbers and dependencies of your caseload. Therefore, you can better balance that caseload across your group of staff. Also with staff such as OTs, who may be sorting the majority of their caseload at home, they traditionally would have had to get the manual records from the office, which could be any one of six offices in a large organisation like this. Whereas with Paris, if the OT doesn’t have a mobile device they can go into any building and access Paris to get the information they require. They do not need to go back to their own office, saving time and money.”

SEBT are engineering within each service before they are implemented, as there is a certain amount of work to do. That is why they decided to go for service-by-service implementation. “Whether the service is large or small, a specialist COPD [chronic obstructive pulmonary disease] multidisciplinary team or 150 district nurses; there is work to be done,” Gillian explained. “All their forms require configuration, all their service specific screens need to be configured onto the system and all the confidentiality levels have to be sorted out, as does their coding. Because we work with joint coding across health and social care it can be a major issue getting coding done across the health family and then to link that to social care in order that we can pull off reports that are meaningful.”

Paris can, however, be used to maintain information in silos if necessary, just as it is currently being done in legacy systems. But the opportunity and potential, which Paris offers, is to open up those silos to see what other colleagues are recording and then take staff through the experience of realising that there is significant duplication of process, assessment process and recording. As Gillian said, “Paris gives the provocation, and the mechanisms with which to engage staff in the process of reducing that duplication, of developing shared understanding and to share processes round assessment. And therefore, be enabled to properly streamline the care plan.”