Overview -The health and social care setting
The context for joint personal care and support planning for people living with health and social care needs will be determined by local decisions about pathways and models of care.
However the following functions will need to be clearly described:
- The groups/characteristics of individuals suitable for personal care and support planning.
- How relevant individuals will be identified.
- Placement on system to prompt person-centred review and initiate process.
- Accountability for ensuring that care and support planning occurs for each person and meets quality standards.
Currently personal care and support planning for personal budgets is familiar to social care practitioners and has been set out in statute since April 2015.
Therefore, some people with joint health and social care needs will currently have personal budgets for social care that have been developed independently of health care and support plans.
In such cases, there will already be a personalised care and support plan to build on when seeking to develop a plan that covers the person's health and care needs and practitioners should work proactively to join these plans up.
What social care practitioners can do now?
- When starting the personal care and support planning process (or reviewing an existing package) for someone with health as well as social care needs, the social care practitioner should contact the relevant health practitioner on a person-by-person basis.
This will enable key health/medication issues to be included in the decision making process and build up working relationships prior to local pathways being developed.
What organisations can do now?
- Ensure that the personal care and support planning process and multi-disciplinary team working described here becomes the driving force in local 'integration' strategies.
Other potential contexts - (see later under 'models of care delivery')
Personal care and support planning involves addressing all the person's physical, mental and social care needs and will often be based in primary care, with a multi-disciplinary team that brings together a range of skills and disciplines. In some communities/or situations the responsibility for personal care and support planning may be assigned to a separate community/speciality or intermediate care organisation.
Personal care and support planning may be commissioned as a preventative intervention, using a risk register or frailty tool and usually based in general practice. Councils may also place social care practitioners in multi-disciplinary team's as part of their prevention duty, providing targeted advice and support around a range of issues to those not currently above the national eligibility threshold for state funded care.
- Individuals already known to adult social care with personal budgets may be referred for joint personal care and support planning at review.