Understanding outcome based support

planning

LUCIANNE SAWYER CBECOMMUNITY CARE RESEARCH & CONSULTANCY

The impact of Outcomes on Support Planning

• Getting support planning right• Brokerage• Resources – not just services• Commissioning – investing not

funding• The market• Measuring outcomes

Aims of support planning – how do we get it right?

• Is the ‘means by which information is presented to release funding’ (DH) but it’s a whole lot more than that as well –– Sets out how to achieve the desired outcomes– What the outcomes are and what the barriers (needs) are– Who will be involved and what do they will do

• Evidence that DH guidance (personalisation toolkit etc) will work well for the most able and most keen to manage things themselves – but what about least able?– Some have little idea about what might be possible– In some cases family or friends may be too protective– Some have no capacity to plan support– Some just don’t want the hassle of doing it all themselves

• IB pilots modelled on In Control – but LD service users likely to have previous exposure to services

• Those in pilots who got an IB were x 5 more likely to already be on a Direct Payment

Support planning – getting it right

• Starts once RAS has allocated resource

• Should focus on bringing about best possible levels of independence, health and well being but must also reflect each person’s own priorities

• Will providing assistance solve the problem? How can we be sure that ‘assistance’ doesn’t skew the person’s own wishes?

• How can we achieve the right balance of power between service user and the council?

• How can we ensure that even the least able can gain choice and control?

• In time, will everyone want to do it for themselves??

Support planning – getting it right

An outcomes approach can help:

• All about the impact that interventions have on a person’s quality of life

• Concerned with bringing about support which is flexible and responsive

• About the person being in control, whether support is via mainstream services or unique to them – but within a framework in which there is shared agreement about the aims

• Ensures the outcomes are the right ones for that person

These should apply to every service user, however they get funding and whether they control it themselves

or not – so long as outcomes thinking permeates all our processes, and way of working

Personalisation – key areas of focus for

Councils• Universal Services

– Applies to everyone, including those who wont qualify for public funding

– Demands universal access to such services as transport, leisure, housing, education

• Early Intervention and prevention

• Choice and Control• Social Capital

– Community, family and friends networks etc.

An outcome-based approach

CONVENTIONAL

• Assessor considers needs in consultation with user

• Assessor identifies tasks to be completed on each visit

• Assessor specifies time of arrival and time of departure

• Monitoring consists of verifying visits and checking tasks completed

• Success is related to efficiency in carrying out visits and tasks according to specification

OUTCOME-BASED

• Service user identifies desired outcomes (priorities) in discussion with assessor

• Assessor considers needs and determines time budget and eligibility. Possibly agrees some tasks with user, but user can change these as he/she wishes

• Provider agrees service plan with user, including times/ days of visits, and tasks – focusing on how best to achieve outcomes. User and provider can agree changes in visit days, times and tasks

• Allocated time can be used flexibly over a given period

• Monitoring will include verifying visits and recording tasks

• Success is judged on whether or not outcomes are achieved

Brokerage - roleConventional role of brokerage:• Identify appropriate choice(s)• Act as a mediator• Should be independent of funders and providers• In the social care context will provide planning supports that are

flexible and are controlled by service user (and family) INTERNATIONAL CONVENTION – SAN DIEGO 2002

DH guidance • Provide a range of information• Undertake, or assist with, support planning• Guidance on choice of support resources• Negotiation, mediation• Facilitation• Provide or access technical skills/information• Advocacy GOOD PRACTICE IN SUPPORT PLANNING AND BROKERAGE

– PERSONALISATION TOOLKIT

Brokerage

An overlap but asuccinct role

Information Support

Advocacy

BROKERAGE

Who provides brokerage?

Brokers must:

• Understand the concept and practice of outcomes working, focusing on what is most important to the person

• Understand local market• Have wide knowledge of local and national resources,

including benefits etc.• Know where to access specialised advice• Have ability to ‘think out of the box’• How to make best use of budget i.e. not just buying paid

support• Be able to design, or assist in designing and costing, support

which supports the person in relation to his desired lifestyle, needs and chosen outcomes

• Have excellent communication skills, including how to help those with communication difficulties

• Have stories (examples) of how others have used budget• Understand issues around capacity to consent

Resources

• Support resources – not just services• Family and friends• Community resources to which we should

all have access• Volunteers or voluntary sector

organisations• Range of specific social care services

– In-house provision– Voluntary or private providers – commissioned

or purchased individually– Individually sourced Personal Assistants

Commissioners need to be investors, rather than

fundersThe Funder

Invites submissions, often to a rigid specification, and selects from those applying

Believes fairness means keeping a distance from proposers

Considers grant or contract decisions the high point of the work

Monitors for compliance

The InvestorSeeks to uncover all promising opportunities and encourages innovation

Believes fairness means intense interaction with applicants

Considers the initial investment only the starting point

Asks: How can I help?

Taken from Institute of Rensselaerville document

Commissioning for outcomes

What is the return on your investment?

CHANGE

• Fewer prisoners re-offend – change in behaviour

• Reduction in the numbers of depressed older people – change in well-being (feelings, attitudes, circumstances)

• More older people remaining independent – changes in mobility, confidence etc.

• Improved mortality rates after heart attacks – change in health

Making the change

• Involve providers as you develop your ideas – get widescale commitment and provide training

• Really get to know your local providers – what area do they cover, what is their capacity, who are the middle managers, how open are they to change?

• Be clear about what you want and expect, but be open to negotiation – what are the problems they foresee in changing what they do and how they do it? How can you help them?

• There are advantages to them as well – staff turnover improves with outcomes working, the potential for learning new skills, and taking more initiative

• Relationships with service users will also improve as providers are able to respond more flexibly and as the service user has control over what is done and what is not done

Joint

commitment to

success

Shared risk

No blameculture

Permission to do things

differently

Open to

Discussing

problems

Good communication

TRUST

AIM AT:

PIE IN THE SKY ?

Measuring outcomes

• Must start with baseline data

• Service outcomes – numbers of people able to continue living at

home

• Individual outcomes – physical or emotional (confidence, engagement

etc.)

• Individual outcomes – simple recording or more complex tools e.g. depression index, quality of life measure

Results Based Accountability approach to measuring outcomes

How muchdid we do?

How well did we do it?

Is anyone better off?

Quantity Quality

‘hard’ and ‘soft’ outcomes

HARD• Observable functional

improvements• Reduction in recidivism or

substance abuse• Young care leavers have

improved academic qualifications

• Carers are able to continue at work

SOFT• Improved quality of life• Reduction in depression• Carers have reduced

stress levels• People feeling more

confident• Older people feeling

valued• Well being

Tools for measuring outcomes

• Scales based on Activities of Daily Living (ADLs) – focus on dependency eg bathing, dressing, continence etc.

• Instrumental ADLs include core activities of independent living eg preparing meals, doing housework, managing finances, remembering to take medication etc.

• A number of QOL surveys being developed – Office for Nat. Statistics leading the Quality Management Framework QMF. Within team PSSRU developing ASCOT which measures value of some social care services – seeks to identify specific aspects of people’s lives addressed by social care interventions – applicable across all user groups

User Defined Service Evaluation Tool (UDSET)

• Investigates users’ or carers’ experience of a service or package of care

• Determines whether the service/care package delivers the desired outcomes

• Understand how different features of the service impact on user/carer experience

UDSET outcomes for Quality of LifeFOR SERVICE USERS• Feeling safe• Having things to do• Seeing people• Staying as well as you

can be• Living where you want

and as you want• Dealing with

stigma/discrimination (mental health)

FOR CARERS• Quality of life for the

cared-for person• Maintaining health and

well-being• A life of his/her own• Positive relationship with

the person cared for• Freedom from financial

hardship

The Outcomes Star Personal responsibility

Living skills

Social network

Substance riskHealth

employability

accommodation

Outcomes Star – type of scale

Number Indicator

1 No motivation

2 Focuses for brief periods of time only

3 Does want to change but feels helpless/powerless to do so

4 Begins to request some help

5 Wants to change and has some idea in what way

6 A clearer sense of what he or she wants and some idea of steps needed to get there

7 Active in getting closer to his or her goal, has a sense of how others see him or her

8 Noticeable change in behaviour, can evaluate options

9 More comfortable with new lifestyle

10 Feel he or she is in right situation/place for forseable future

Data for measuring outcomes

DH recommends:• Should be available at PCT and/or local

authority level• Regularly available• Statistically robust• An appropriate measure of the framework

outcomes• Avoid perverse incentives etc.• Promote improvement