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Although it is felt that there is common information within care plans beyond the “What’s Important to Me?” statements, phase 1 data scope will be used within a technical ‘proof of concept’ which aims to address current challenges and barriers to sharing common data sets between organisations and across forms and systems.
Problem statement
Care is planned in different ways across the city in a variety of settings. Personalised ‘About Me’ type questions for patients are captured in different systems, using different questions. These are not shared effectively between care settings. This means that people are asked the same thing multiple times and professionals waste time repeating similar conversations. Patients may feel disengaged as a result and frustrated by the lack of joined-up care planning.
Context of use
Settings and roles
Collaborative Care and Support Plan (CCSP): Incorporate WMTM questions within template re-design and include the WMTM questions as an initial prompt within the patient letter with the test results. Incorporate WMTM and guidance into Long Term Conditions Training.
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Frailty / Welfare Check Template: Re-design of Welfare Check Template to address placement of the WMTM questions. Re-‘roll out’ of the template to Care-Coordinators within PNC’s.
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Advanced Care Planning / Planning Ahead Template: Incorporate WMTM questions into the new ‘Planning Ahead’ template which will see EPaCCs and ReSPECT combined into one template for use within LCH, Primary Care and Hospices.
Cancer Care Support Service (CCSS) / S1 Template: Incorporate WMTM questions into the CCSS S1 Template.
Social Prescribing / Wellbeing Plan: Incorporate WMTM questions into a new template (Wellbeing Plan) to be used by linking Leads’ Social Prescribers
Target Systems
Support the use of existing SystmOne functionality to share information (captured in templates) across community and primary care settings.
Implement the required functionality (based on both technical and functional requirements) to capture the answers to the WMTM questions in Helm (Person Held Record) and share with Yorkshire Humber Care Record (YHCR) / System of Systems (SoS).
Implement solution to process information captured in templates in SystmOne Community units via the YHCR/SoS (TPP community adaptor). This will involve mapping data with appropriate transformations to relevant questionnaire FHIR resources for sharing via YHCR / SoS.
Implement solution to process information captured in templates in SystmOne and EMIS GP systems via the YHCR/SoS (GP Connect adaptor). This will involve mapping data with appropriate transformations to relevant questionnaire FHIR resources for sharing via YHCR / SoS.
Develop interface (based on both technical and functional requirements) to display the answers to WMTM questions in Helm (Person Held Record) that have been authored by professionals in other settings and subsequently shared via YHCR / SoS.
Develop interface to both capture and display answers to WMTM questions in the YHCR Care Portal that have been authored by professionals in other settings and subsequently shared via YHCR / SoS. This will be based on work completed in Helm as it shares the same architecture.
Support the development of the user interface within the Leeds Care Record (LCR) in order to present WMTM answers derived via YHCR / SoS.
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Theme | Questionnaire Sharing |
Initiative | HQ001 - Helm questionnaires shared with professionals |
User Journey Summary | Patient/homelessness peer capture of ‘What Matters to Me’ questions in Helm for sharing with professional users via YHCR Portal (and any other SoS connected consumers). |
Information provider roles | Patient, citizen, homelessness peer advocate |
Information consumer roles | GP, practice nurse, care coordinator, secondary care clinician |
Supporting Work | Alignment to PRSB standards, NHSI/E co-design groups for personalised care. |
Alignments / Support | ICS priorities for personalised care and inclusion agenda (Bevan) |
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FHIR profiles and resource mapping
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