Person Centred Co-ordinated Care.
What are the critical components for, obstacles to, implementing person centred co-ordinated care.
written using the English language NOT AMERICAN… please ensure all words are spelt using the English word and refer to the UK
provide a rich perspective on the needs of the patients or users that you and your team members support directly or indirectly; challenging you to explore how patients, service users, carers and families can be involved in developing better and more joined-up services.
please can you touch on the socioeconomic status in the Uk and compare it to Salford Manchester when considering person centered care, you could include public and social value and relate this to how Salford Royal Foundation trust support person centred co-ordinated care.
Can you mention leadership, from a senior nurse perspective as well as citezenship, co-production, independent living, intergrated working, health in-equalities. can you also mention adaptive leadership, wicked problems
The learning outcomes, I need to demonstate in the assignement are listed below
Knowledge and Understanding
• Critical awareness of the national and international evidence of effective system wide co-ordinated care
• Theoretical and practical knowledge of complex adaptive systems
• Critical awareness of approaches to shared decision-making and their practical application
• Critically evaluate evidence of system wide coordinated care
• Apply theories and models to aid understanding of complex adaptive systems
• Analyse and critique the practical application of approaches to shared making
• Apply theories and methods of reflective practice Practical Skills
• Demonstrate practical skills in networking, influencing and sharing decision making
• Demonstrate practical skills in making sense of quantitative and qualitative organisational data
Transferable Skills and Personal Qualities
• Demonstrate skills for implementing and evaluating
system wide co-ordinated care
Your writing must show evidence of theoretical concepts and critical analysis and should be applied to the workplace where appropriate to demonstrate synthesis of knowledge.
•When offering ideas and concepts, you must support these by drawing on relevant evidence – that is theories, concepts and models – from the literature. Core texts and further reading
Critical Components for, and Obstacles to, Implementing Person centred Coordinated Care
Person-centred coordinated care is the type of the care system which is aimed at fitting somebody’s health and their social needs. The person who is receiving the health care services, as well as those who are providing the health care services, have to fit in all the health care structures for the goals of providing the care system to be achieved. Person centred Coordinated care is aimed at improving people’s wellbeing both mentally and physically which will, in turn, improve the quality of life they live. The quality of their lives could be enhanced as a result of the patients or those receiving the health care services being relieved of their stresses or being guaranteed of their future. Personal centred Coordinated care is mainly used to encourage both functional independence and to manage a particular medical condition. The need for person-centered coordinated care is increasing on a daily basis since people who are living with long-term medical conditions as well as aging people are increasing hence the essence to provide coordinated care to them. Person-centred care is very crucial because of several reasons. First, it helps those who are depending on the care services to gain knowledge and confidence about themselves hence they get into a position where they can make better decisions about their health and the issues surrounding them. Secondly, this type of care system is designed such that it caters for all the needs of the person who is receiving the services. The needs of a physically challenged person automatically vary with those of an aged person. Hence the designed system will concentrate on every person’s needs independently of the other. Additionally, this kind of care system ensures that the people being offered the service are treated with respect and the dignity they deserve hence they get to recover or gain their confidence faster. The purpose of this paper is to discuss the critical components for, and obstacles to, implementing person-centered coordinated care.
Key Components for Implementing Person-centred Coordinated Care
There are four key components when implementing person-centred coordinated care, and they all have to be applied together and in the right manner for the goals and objectives of carrying out this kind of care to be realized (NHSIQ, 2016 p. 1). The first key component is commissioning which is the process of improving the health system so that the output of one cycle can inform the next in the right way for the desired goals to be realized. Commissioning is aimed at providing quality treatment to people living with long term medical conditions and also giving them the required care hence when they die, they will die with some sense of dignity. Commissioning assists in achieving the anticipated results. While commissioning, the patient need to be well informed by the care provider so that any attempts taken by the care provider to improve the life of the patient will work. Proper commissioning should even include the families and friends of the patient so that the care provider gets to know much about the patient.
Good Commissioning involves five stages. The first stage is the person receiving the care to develop a vision and strategy of their life (Ekman et al. 2011 p.45). In developing the vision and the strategy, the patient needs support and assistance from friends, families, and the care provider. By developing a plan for their life, the patients will be able to live a happy life. The next stage is the gathering of information which involves gaining information from various quarters so that the care administered to the patient suits their needs. The needs that a physically challenged person requires vary from those of a person living with a long medical condition hence getting the facts right is important while administering personal care. The third stage relates to planning and specifying the outcomes that the care system is expected to provide so that they can fulfill the needs of the patient. In fact, the plans should be designed such that it is possible their outcomes even outdo their expected results. In case the desired results fall short of the needs of the patient, then the commissioning process will have been a total failure (Ekman et al. 2011 p.56).
The fourth stage in the commissioning process is the procurement which is essentially used when making decisions during the commissioning process. This step is essential since it provides the chance to form an alliance of providers where people can freely exchange information which leads to improved decision making. The last stage in the commissioning process is monitoring the improvement from the patient. In this stage, the services that the patient has been provided with are looked into, and ways on how they can be improved are designed. The services designed should have the following characteristics; first, they should be secure by making sure they are of a high quality. Secondly, they should be efficient, and lastly, they should encourage a good relationship between the patient and the person providing the service.
The second key component of person-centred coordinated care is engaged and adequately informed individuals who promote self-management support by providing the required information and also the resources which are used in designing the personal budgets (Health Foundation, 2016). This kind of assistance is critical to people who happen to be living with long term medical conditions since it helps them to have authority on many aspects of their health at all times. The aspects could be either medical or emotional. The self-management support provided by those informed individuals is crucial since it has the aspect of enabling people to be in charge of their personal health and also giving them the support they need so as to meet their needs.
This component is relevant as a key element of personal centred coordinated care since it merges the principles of enabling and personalization of care. In person-centered coordinated care, care is taken to be both enabling and personalized. It is enabling in the sense that, the patient gets the authority to control their health through positive thinking and confidence. The principle of personalization is manifested through the process where this care system is designed to meet the needs of every person independent of the other. Different individuals and patients have different needs hence the kind of attention given to them is intended to help them overcome those needs. It is only people who are well trained in this field of providing care to this groups of individuals who can promote self-management support since they have the relevant education.
The third key component of implementing person-centred coordinated care is health professionals working in partnerships with care professionals which result in shared decision making. The process of exchanging information and coming up with an absolute decision is achieved only when the health professional work in partnerships with health counterparts and also involving the patients as well (NHS England, 2016). The component of partnerships which result in shared decision making remains to be a critical part of person-centred coordinated care because of two reasons. First, it brings out the principle of personalization since those undertaking care services are given the chance to determine the outcomes they would wish the care service will result to so as to be able to meet their needs and also allowed to propose ways they think could help them achieve those outcomes faster and easier. Secondly, it brings out the principle of enabling as it allows the patients to be exposed to a variety of treatment options from where they can choose the ones they feel are better for them. Shared decision making promotes an efficient culture in clinical implementation by increasing the period of engagement between the service provider and the patient and also by creating a platform where people from different quarters can share their experiences or those of others. This component works with the principle that no decision should be made about somebody without them being included in making that decision. Patients get the chance of getting answers to the questions they raise on the available solutions they are exposed to hence they get the opportunity to make a more informed decision (NHSIQ, 2016). For shared decision making to be efficient, there should be harmonious existence between the patients and the health care professionals so that whatever route they decide on following in catering for the needs of the patients will work.
The last key component for implementing personal centered coordinated care is the organizational and the clinical processes involved which encompass the safety as well as experience. The methods that are used while applying this kind of care should be designed to satisfy primarily all the needs and the requirements of the patients as well as the service provider using a broad range of information. Organizational and the clinical processes could be manifested in three ways; digital health, health literacy, and integrated care (Health Foundation, 2016). Digital health refers to all those technological inventions that are required so as to promote a person’s health without the individual being required to visit the hospital in person. The advantage of digital health as a clinical process is that it can easily be designed to fit the needs of different kinds of people hence the aspect of personalization. The needs required by an aged person are different from that required by someone who is suffering from a long-term medical condition like chronic cancer. Digital health also promotes the principle of enabling since people are given authority of their health as well as their care. A real application of digital health is where patients are provided with platforms which allow them to book appointments with their service providers online.
Health literacy, on the other hand, describes the ability people have to comprehend, being exposed to, and capacity to use certain health information or services (Health Foundation, 2016). Health literacy is nowadays being used to check on how good an organization is when it comes to responding to the requirements of its patients. Health literacy is a critical clinical process since it enhances the principle of personalization because every patient’s needs are taken care of independent of the other. Integrated care as a clinical process refers to improved coordination in the organization with the aim of providing better healthcare services to the patients. Integrated care is a useful organizational process since it enables the care to be coordinated with the needs of each patient (Health Foundation, 2016).
Obstacles to Implementing Person-Centered Coordinated Care
There are various challenges faced when administering the person-centred coordinated care. First, is the lack of the human resources and more so the general practitioners (Bodenheimer, 2008). In practicing person-centred coordinated care, some patients may have complicated conditions and therefore require a lot of time in which they need the attention of the general practitioner who happen to be few compared to the large number of patients awaiting their services. The general practitioner, therefore, might not achieve the full needs of every patient as they have to multitask attending several patients in a day which might make this care system ineffective. Lack of a general practitioner leads to a slow process when it comes to providing and implementing the person-centred health care services.
Secondly, there is the obstacle of financial constraints while implementing person-centred coordinated care. These shortfalls arise since some patients have some chronic diseases which bring about other disorders which make it expensive to control the medical condition. Providing personal care to patients with chronic conditions or other long term complicated medical conditions outweighs the safety net costs budgeted by the health care providers which makes it hard for them to execute these duties in a professional manner. Financial constraints may also arise due to less funding for the net service providers from outside sources (Goodwin et al. 2013). Most institutions that provide health care services get funding mostly from one outside source and the funding they get are barely enough to increase the number of staff that are required to attend to all the patients or even to meet the demands they get from the patients. On top of the high costs, most of the efforts that are undertaken by the health care providers go unnoticed, and nobody gets to reward them for their good job. Most of them as doing what they are being paid to do hence do not appreciate the good work they do while other people might view them doing what everybody else would be in a position to do hence no recognition is given to them.
Thirdly, providing efficient personalized care services for those people who reside in rural and other remote areas of a country has become an obstacle while implementing person-centered coordinated care (Goodwin et al. 2013). People living with long-term medical conditions and live in remote locations present a lot of challenges since the general practitioners have to spend a lot of time while commuting to those areas and using a lot of resources just to attend to one or a slight number of people in that location. The road infrastructures in most remote areas are poorly developed which leads to delays hence many health care service providers fail to get to the patients when the patients might be needing them most. Person-centered coordinated care can only work in remote and other areas if and only if the situation the patient is passing through is identified at an early stage which makes it possible for long-term solutions to be given.
Fourthly, communication barriers are a significant challenge when it comes to implementing person-centered coordinated care. When performing this kind of care, there might exist four types of communication barriers as Bodenheimer (2008) outlines. First, the linguistic background of the general practitioner or the person administering the service might vary from that of the patient hence there is no effective communication. In the provision of person-centered coordinated care, there should exist shared decision making between the patient and the care provider which only results through the exchange of views and experiences hence better plans are designed to suit the patient’s needs. If the patient and the health care service provider cannot converse with each other, then the essence of providing this kind of care is lost in the process. Secondly, the two might not have universal values in the way they view health matters and illnesses. A common phenomenon which I have encountered in my workplace is where the patient is resistant to taking some drugs with the faith that it is God who heals and not the medication. It is always a challenging ordeal for the health care provider to convince the patient that they need to take medication. Thirdly, the two might bear different role expectations. The differences in role expectations make it hard for the two to understand each other since the actions or proposals given by one party are irrelevant to the other one. Lastly, there might exist the aspect of prejudice between the two sides which make them talk to the other in a biased way. The two might judge each other for who they are not hence making the interaction not to be a productive one.
Fifthly, lack of informational continuity is another obstacle that is hindering the implementation of person-centered coordinated care. There exists a lot of care records, but most of them cannot be accessed by patients which affect the aspect of shared decision making. For shared decision making to be effective, the patient needs to be exposed to all the materials and information which stresses on the needs of their condition so that they can make an informed decision about the kind of route the service provider should take while attending to their condition (Barry and Edgan, 2012). Patients who are exposed well to all the relevant information get to ask controversial questions which they might not be in a position to seek answers hence they get to know the repercussions of each decision they make before they do it. On addition to the lack of accessibility to available information by patients, there exists the challenge of lack of a common IT system that enhances the exchange of information between the health systems and the care systems which leads to a gap in the means of communication between the various parties. Some patients, for instance, prefer to make calls to their health care providers who on the other hand might prefer emailing as the mode of communicating with the patients. Lack of a common channel while communicating results to a breakdown in the communication processes which results in delays in service delivery.
Sixthly, lack of encouragement and support to the staff from their superiors can pose serious challenges while implementing the person-centered coordinated care. The way the organizations are organized and managed may either influence the working staff positively or negatively in the way they execute their duties as Bodenheimer (2008) asserts. Most superiors are accustomed to being instruction-givers rather than being team leaders. Additionally, they lack to promote the workers who do a good job through incentives hence lack of morale on the part of the staff while implementing their duties. Additionally, some cultural beliefs and norms tend to hinder the implementation of the person-centered coordinated care. Some cultures do not believe in the administration of modern medication since they have been accustomed to the traditional herbs and medicines. It becomes challenging for the medical practitioner to convince the person to take the current medication which acts as an obstacle to its implementation.
Person Centered Coordinated Care can be very fruitful if implemented well by all the stakeholders. The reason is that the patients will be attended at personal levels, and they will also be involved in the major decisions that are made concerning their lives. As discussed above the person-centered coordinated care has four key components which are commissioning, partnerships of health and care professionals, engaged and informed health care individuals, and organizational and clinical processes. Implementing this kind of attention system has faced several challenges in its implementation, and some include financial constraints, communication barriers, inadequate human resources, and lack of information or inaccessibility of the available information by the patients.
Barry, M.J. and Edgman-Levitan, S., 2012. Shared decision making—the pinnacle of patient
Centered care. New England Journal of Medicine, 366(9), pp.780-781.
Bodenheimer, T., 2008. Coordinating care-a perilous journey through the health care system. New
England Journal of Medicine, 358(10), p.1064.
Ekman, I., Swedberg, K., Taft, C., Lindseth, A., Norberg, A., Brink, E., Carlsson, J., Dahlin-Ivanoff, S., Johansson, I.L., Kjellgren, K. and Lidén, E., 2011. Person-centered care—ready for prime time. European journal of cardiovascular nursing, 10(4), pp.248-251.
Goodwin, N., Sonola, L., Thiel, V. and Kodner, D., 2013. Coordinated care for people with complex chronic conditions. Key lessons and markers for success. London: The King’s Fund. (Remote, GP, Funding).
NHS England. 2016. Person Centered Health and Shared Decision Making. Available at: http://www.nescn.nhs.uk/common-themes/ltc-shared-decision-making/ [Accessed 24 Jul. 2016].
NHSIQ. 2016. Person-centered coordinated care. Available at: http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/long-term-conditions-improvement-programme/house-of-care-toolkit/national/person-centred-care.aspx [Accessed 24 Jul. 2016].
Health Foundation. 2016. Approaches and key components of person-centered care. Available at:
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