NHSNHS Improvement

1. Get the right people involved2. Give the patient and carers the right information to enable

their involvement3. Plan for the whole person4. Use a standardised system5. Integrate with the rest of the pathway

• Involve patients and carers todevelop your information to get thecontent and style right

• NICE stroke quality standard 111

requires carers to be provided withinformation about the caremanagement plan.

Get the right people involved

• Get social care involved early whenchanging your care planning process

• Representatives from both healthand social care who are supportingthe individual and are aware of theirimpairments and aspirations shouldbe involved in the development ofthe care plan, with the individual andtheir family if appropriate

• Joint care planning will be enhancedby early, active involvement by arepresentative from social care.

PRACTICAL PRINCIPLEShow to establish joint care planning

Plan for the whole person

• The plan should consider the wholeperson and encompass all of theirongoing issues including theirrelationships, finances, leisure etc,and not just the clinical and physicalmanagement of their stroke

• The plan should be owned by theindividual (or their carer if theindividual is unable to participate),who must be involved in itsdevelopment

• The document should support theempowering of individuals to haveownership of their own care

• The individual should have a copy ofthe joint care plan.

CASE STUDY

12QUALITYMARKER 7

ACCELERATINGSTROKEIMPROVEMENT

Greater Manchester andCheshire Cardiac and StrokeNetwork felt that greaterengagement with social servicesmay have facilitatedimplementation.

CASE STUDY

The team from Musgrove ParkHospital, Taunton and SomersetNHS Foundation Trust removedall medical terminology fromthe standard form and changedthe content added by staff,following feedback frompatients and carers.

Give the patient and carers theright information to enable theirinvolvement

• The individual and carer shouldreceive the right information, in aformat they can understand and atthe right time, to make informeddecisions about what their care planshould comprise

• The care plan should be written inplain English and contain no jargon,abbreviations or medical or socialcare terminology

NHSNHS Improvement

Use a standardised system

• A standard form means you can getagreement from the multidisciplinaryteam, including social care, aboutthe key aspects to cover, and canhelp to ensure equity of service

• There are a number of modelsavailable to use, you may want totest them and modify them for yourlocal area.

Collect data for the joint careplanning measure at point ofdischarge from hospital.

STROKEACCELERATING

IMPROVEMENT

1 NICE stroke quality standard, National Institute for Health and Clinical Excellence, 2010.

CASE STUDY

Greater Manchester andCheshire Cardiac and StrokeNetwork found that althoughthey had a standard form andprocess, implementation at eachsite needed local solutionsrather than a generic process.

For more information and casestudies, please visit the NHSImprovement website:www.improvement.nhs.uk/stroke

CASE STUDY

Solent NHS Trust worked on anumber of drafts of their form,developed with the whole team,and refined the form followingtesting its use with patients.

Integrate with the rest of thepathway

• The joint care plan written ondischarge from hospital should be anevolving document, developed as theindividual’s needs change and inconjunction with communityproviders, primary care, the voluntarysector and social care

• It will help if it also links with sixweek, six month and annual reviewprocesses.