Reaching new heights with highly personalised care

What is integrated care’s next big move? We believe the obvious next step is using digital tools to help people record and share what they and/or their families consider their most important information while they are being cared for.

Using IT as an enabler, combined with joined-up personalised care, we have the potential to elevate care to new heights while supporting tomorrow’s NHS as it increasingly relies on people being more involved in their care to reduce the strain on services.

How did we get to this pivotal moment? 

During the initial phase of digitising health information, the emphasis was on eradicating paper and digitising local care records to support an individual’s care. Fast track to today and the priority is joining up an individual’s care information from various health and social care organisations across Integrated Care Systems (ICSs).

There’s still lots to do in this phase but the evidence from frontline care is already compelling. Working with our strategic Care Alliance partners, System C, we have put interfaces in place between social care systems and health systems for a number of our customers, which are in use today, facilitating more collaborative working.

The benefits of integrating health and social care information across care systems for people and care professionals are clear and it's the potential to use powerful, actionable data insights for population health, is already being realised by several of our customers.   

Integrated health and social care along with population health will elevate a care system’s service offer significantly, but there is potential to raise the bar further. Implementing information standards consistently, such as the About Me profile, to personalise an individual’s care will be the next step to improve care even more.

Shifting the perspective to personalised care

The shift to personalised care is the driving force behind our investment in developing information standards across our solutions and why we have joined forces with the Professional Record Standard Body (PRSB).

Graphnet has been developing its information standards alongside its shared care record and population solutions for some time.  

In 2017 we saw an opportunity for an integrated module within our integrated care record solution to share information about an individual which isn’t normally captured in clinical systems. At the time, there were myriad different hospital-/health-/personal- passports, say it once, all about me variations; with over 20 different versions in use at one point in the UK. 

It was at this point that we collated patient, citizen, and care team feedback to create our own integrated personal passport with six key headings. Through patient engagement workshops, these were refined down to three key headings:

• I want you to know - top likes and dislikes, most important things to me, perceived strengths and weaknesses
• Important things to know in an emergency - contacts, wishes known and discussed with family, future care wishes
• How I live - more information about their living details than is usually available, what personal support they have, etc.

These were all brought together under the heading of “All About Me” within the myCareCentric Personal Health Record (PHR).

The power of this module is that it enables the individual to record in their own words what they feel is important, what they think is missing from their clinical records and in their own words what their hopes and aspirations are with regards to their care. If they also have an Integrated Care and Support Plan, this information saves the clinical team time and gives them an insight into how the individual is thinking; perhaps what is important to them is not the same as the standard pathway goals.

We found that the main part of our “All About Me” was very closely aligned with the PRSB’s “About Me” section of the Personalised Care and Support Plan and so with a small amount of configuration re-design we could be completely aligned. Further amendments were made as the standard evolved, and our users know that we are following the latest national guidance. The other parts of our module are still important to our users, and we were able to feed that back to the PRSB team. We see that two-way collaboration as being key and why we wanted to join their Standards Partnership Scheme.

Strength in partnership working

Graphnet joined the scheme at the beginning of the year but more recently the whole System C & Graphnet Care Alliance decided to follow suit, after seeing the strong relationship and progress we have made since partnering. The About Me standard  is just one part of Graphnet’s work with the PRSB. We are working on a number of standards and developments to align our solutions and the Alliance is extending this work to support the implementation of standards across its integrated IT solutions for social care and education management, electronic patient records, medicines management and remote monitoring.

Today the About Me standard is implemented across six of our customers covering approximately ten million care records. During COVID-19 monitoring, About Me and the corresponding sections were used thousands of times by patients and care teams, particularly during winter 2021/22.

About me guided principle

Our “about me” approach helps us to better design new content. The needs of the individual may not always align with set care plans, so we need to be mindful of allowing the person to record what they want to record in their own way. We make it clear that this is not directly monitored but that it is available at the point of care, as and when it is needed. The tight integration between shared care records and the PHR, along with the close relationship with the PRSB, are key elements of our approach.