Common Components of Care

Owned by Toby Page
Last updated: Jan 19, 2021

Background

All health and care organisations and specialisms have a myriad of care plans and many of them have some similar information fields / data sets.  Formally known as ‘Componentisation of Care’, this project aims to reduce the division between primary, secondary, community, voluntary and social care organisations by establishing standardisation of data sets and enabling information to be shared between organisations and across forms and systems.

 The current phase of this work is focused on establishing a technical method that will allow sharing to take place. The technical focus is on flowing this information from organisation systems to the Yorkshire and Humber Care Record (YHCR), and then to the Leeds Care Record. 

 A series of ‘What Matters to Me’ data items (personalisation questions) have been chosen to prove the technical method. Currently information relating to what matters to a person is not effectively shared between organisations involved in an individual’s care.  Although some staff involved in the care of an individual, can see and share some aspects of this information digitally via the Leeds Care Record, others cannot, more typically those from the independent sector or VCSE.  This results in discrepancies and people being repeatedly asked the same questions.   Furthermore, the person receiving care is often unable to view and update this information.  Once we have proved that we can flow the ‘What Matters to Me’ information, we will be taking soundings from people within the system as to the next priority data items.  

First year Objectives

Standardisation of “What Matters to Me?” (WMTM) questions

  • Establish a standardised list of ‘What Matters to Me’ questions for use across the health and care system.

Phase 1 Forms and Templates for ‘What Matters to Me’ inclusion

  • Collaborative Care and Support Plan (CCSP):

  • Frailty / Welfare Check Template:

  • Advanced Care Planning /  Planning Ahead Template:

  • Cancer Care Support Service (CCSS) / S1 Template:

  • Social Prescribing / Wellbeing Plan

Phase 1 Digital Applications for ‘What Matters to Me’ inclusion (Helm)

  • Helm (Person Held Record):  Incorporate the ‘What Matters to Me’ questions within Helm (Person Held Record) so that a person can view and edit these at any time.

  • Enable a person to record the answers to the ‘What Matters to Me’ questions in Helm (Person Held Record) and share with Yorkshire Humber Care Record (YHCR) / System of Systems (SoS).

  • Develop technical and functional features to display the answers to the ‘What Matters to Me’ questions in Helm (Person Held Record) that have been authored by professionals in other settings and subsequently shared via YHCR / SoS.

  • Facilitate the development of a ‘questionnaire widget’ to enable surfacing of the ‘What Matters to Me’ responses in Leeds Care Record derived via YHCR / SoS.

Sharing ‘What Matters to Me?” responses with Professionals, regardless of what care system is used

  • Identify solutions for sharing ‘What Matters to Me’ responses to meet the requirements of the Third sector, NHS organisations and Leeds City Council.

  • Establish how the ‘What Matters to Me’ responses will be accessed and presented to professionals to best inform care within existing and evolving workflows. 

  • Establish the required functionality to allow professionals to input consistent  information regardless of what care system they use; which can then be share with (and understood by) other people involved in a person’s care.  

  • Support the use of existing SystmOne functionality to share information (captured in templates) across community and primary care settings.

  • Implement a 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 a 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 an 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.

  • Facilitate the development of a ‘questionnaire widget’ to enable surfacing of the ‘What Matters to Me’ responses in Leeds Care Record derived via YHCR / SoS.

3rd Sector Information Governance Support to gain access to Leeds Care Record (LCR)

  • Undertake Information Governance (IG) work with a number of third sector organisations who are commissioned to provide direct care to people, to enable access to Leeds Care Record (LCR) and YHCR / SoS.  

  • Establish and communicate cost effective alternative options to adhere to the technical connectivity requirements for Leeds Care Record (LCR) access.

Progress to Date

The COVID-19 Pandemic resulted in an initial 3 month delay of this work. 

 ‘What Matters to Me’

  • A ‘What Matters to Me’ Sub-Group has been formed to own the ‘What Matters to Me’ data items, agree data inclusions, changes and related guidance.  Additionally, members of this group will promote the use of the ‘What Matters to Me’ questions within their respective areas and prioritise the further inclusion of these data items within additional forms and templates.

  • The initial 4 ‘What Matters to Me’ questions are now live in the following S1 clinical templates:

    • Personalised Care section for use by PCN based Care Coordinators:  Live Dec 2020

    • Cancer Care Support Service (S1 Template): Live Dec 2020

    • Next Go Live of WMTM will be within the Planning Ahead Clinical Template, due for roll out 22nd Jan 2021.

Phase 1 Digital Applications for ‘What Matters to Me’ inclusion (Helm)

  •  A survey was released to understand people’s appetite for adding, updating and sharing their ‘What Matters to Me’ answers using an online application such as Helm and high level requirements have been captured for inclusion of the ‘What Matters to Me’ questions within Helm (Person Held Records).

  • There is ongoing consultation with the Leeds Care Record (LCR) Team for development of a ‘Questionnaire Widget’ within LCR to surface the ‘What Matters to Me’ responses flowing from Helm.  A case for the questionnaire widget was taken to Leeds Care Record Board on 2nd Dec.

Technical Solution: - Sharing ‘What Matters to Me?” responses regardless of what care system is used

  • Continued work with PRSB, UK Terminology Centre (NHSD) and YHCR Data Architecture & Design Authority (DADA) for validation of selected codes.   This has included working with the co-design group for personalised care (NHSe/ improvement) who are acting as an expert reference group to assist the PRSB in delivering a minimum data standard for Personalised Care and Support Planning as there will be natural overlap.

  • Continued work on solution Architecture and FHIR resources: design for information sharing.

3rd Sector Information Governance Support to gain access to Leeds Care Record (LCR)

  •  30 Third Sector Organisations approached to date.

  • 6 Information Audits complete.

  • 6 Leeds Care Record Applications in progress: Age UK. Aireborough Voluntary Services to the Elderley (AVSED), Carers Leeds, Cross Gates GNS, Seacroft Friends and Neighbours, Touchstone.

  • 2 LCR Applications submitted and pending approval (Touchstone, Forward Leeds).

  • Gathering of real world / practical examples of how the 3rd Sector is delivering care at present whilst accounting for diversity within the sector.  Initial work has been fed into LIGSIG to communicate the key role of the 3rd sector in health and care and the need for 3rd sector access to the right information, tools and resources as a result.

  • Assessment of options for more streamlined, safe and cost effective access for the 3rd sector to Leeds Care record.  Additional options proposed for assessment and appraisal. Consultations with the Leeds Care Record Team regarding the connectivity (HSCN alternative) options being assessed and a case for an ‘Internet First’ approach for Leeds Care Record was taken to the LCR Board on 2nd Dec.