keith barry & leigh allen

Care Pathway Planning

Comprehensively simple

Keith Barry, Group Head of Nursing

Leigh Allen, PathNav Clinical lead

Introduction and

Overview

Taking quality to the highest level • Working together • Caring safely •

Uncompromising integrity • Valuing people

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Construct of a Care Pathway Plan

The plan (or Care Plan) might include:

1. Context for how you arrived at the start of the journey, what’s going to help you along the way, and what’s going to impede your progress. Who are you traveling with, and what do they bring? (Formulation/Needs Assessment)

2. Clarity about the end destination & the route you’re taking (Pathway map)

3. Knowing what you need to do to get from point to point in the journey (Health outcomes/goals)

4. A training plan. What skills and abilities am I going to need to accomplish the journey? (Activity/Therapies)

5. What’s the plan if I get ill or need help along the way? (Support plans)

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Formulation Pathway plan Health outcomes Special

arrangements

Describes the risks, contributing factors, skills and vulnerabilities of the patient which informs health needs and goals.

A simple plan that illustrates/describes the expected/proposed pathway through services a patient will take to the community or to the most realistic final service destination.

I.e Medium Secure, In-patient Rehabilitation, Supported Living.

A detailed plan defining overarching outcome areas (or domains) and specific outcome items that will help achieve that outcome area. It will detail the interventions necessary to achieve those health outcomes. This plan is likely to be a medium to long term plan reviewed at care review meetings. Every patient should have a copy of their outcomes plan and know which outcomes are critical to achieving the pathway plan.

I.e. Outcome – Developing Insight. Outcome item - Insight into my mental disorder,. Intervention –Mental Health Awareness programme.

An individual plan developed and managed at ward level that describes the routine management of a persons care or the control of immediate risks. One plan may address multiple items of concern.Likely to be reviewed routinely at ward level in nursing or MDT meetings and may feature in Care Review meetings.

I.e. Advance directive, how obs are managed, management of self harm, management of violence, specific security considerations, specific family, contact, visiting considerations etc.

Sources:

PathNavPathNav PathNav Clinical record

RIO/Carenotes

etc

Activity

timetabling



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2. Destination & route

Learning:

•Testing with clinical teams shows that for most patients it is possible to make a reasonable judgement about the final and most realistic point in a patient’s journey.



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2. Destination & route

Learning:

•Testing with clinical teams shows that for most patients it is possible to make a reasonable judgement about the final and most realistic point in a patient’s journey.

•When you have mature, multi-disciplinary and ‘evolved’ clinical teams it’s not at all difficult. Where the problems arise is when teams are suffocated by feeling they need to use all parts of the pathway.

•Most often, patients value seeing the full picture of their journey and the services they’ll use. It often repositions their ideas of the next point in the pathway.

•It does demand though, that we’re more open about those patients who are likely to reach the limit of their integration with the community in inpatient services. We’ve referred to this as enduring care.



3. Health outcomes

Patient experience

measures

Life goals/aspirations

and hopesInterventions

Factors a person feels are important to their care or to the experience they have while in care. Patient-defined experience measures do not always fit perfectly with health outcomes but should always be listened to and where possible taken into account.

Important goals people want to accomplish in life or ideals they wish to uphold. These should be properly understood by a clinical team and supported where it is reasonable to do so.

Treatment and therapy packages that might (or might not) support health outcomes i.e. CBT. Completion of intervention does not necessarily mean a health outcome has been achieved.

Risk management

arrangements

Special Arrangements to prevent, minimise or manage understood risks. i.e. 1-1 observation, access to high risk items or observation of visits etc.

Personal support

arrangementsSpecial Arrangements to support personal care, physical health or other cultural/personal needs etc. i.e. personal care plan, detailed chronic condition plan etc.

Health outcomes

The specific health result a patient and clinical team need to achieve (or contribute to) together to enable the treatment pathway to be completed. They need to be specific, measurable and fair.



3. Health outcomes

Patient experience

measures

Life goals/aspirations

and hopesInterventions

Factors a person feels are important to their care or to the experience they have while in care. Patient-defined experience measures do not always fit perfectly with health outcomes but should always be listened to and where possible taken into account.

Important goals people want to accomplish in life or ideals they wish to uphold. These should be properly understood by a clinical team and supported where it is reasonable to do so.

Treatment and therapy packages that might (or might not) support health outcomes i.e. CBT. Completion of intervention does not necessarily mean a health outcome has been achieved.

Risk management

arrangements

Special Arrangements to prevent, minimise or manage understood risks. i.e. 1-1 observation, access to high risk items or observation of visits etc.

Personal support

arrangementsSpecial Arrangements to support personal care, physical health or other cultural/personal needs etc. i.e. personal care plan, detailed chronic condition plan etc.

Health outcomes


Health outcomes




3. Health outcomes

Learning:

•Health outcomes map over the entire pathway. There aren’t outcomes for medium secure and outcomes for low secure. There are outcomes for people.

•Defining the progress points (or steps) within an outcome in relation to the pathway is really important. Grading 1-5 just isn't good enough.



3. Health outcomes map over the pathway



3. Health outcomes

Learning:



•Distinguishing which health outcomes are ‘Pathway critical’ and which you can take with you are really important.



3. Health outcomes

Learning:

•Health outcomes map over the entire pathway. There aren’t outcomes for medium secure and outcomes for low secure. There are outcomes for patients.



•‘Static’ outcome tools miss an opportunity to be helpful. Being able to ‘bin’ outcomes that aren't relevant and being able to write patient specific outcomes is critical to any outcome tool being safe, clinically sensitive and personalised.



3. Health outcomes

Learning:




•Static outcome tools miss an opportunity to be helpful. Being able to ‘bin’ outcomes that aren't relevant and being able to write patient specific outcomes is critical to any outcome tool being safe, clinically sensitive and personalised.

•Making a clear link between interventions and outcomes is important.



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Summary

• Having a clear pathway is critical, but it’s only part of a much more comprehensive approach

• Clearly stated heath outcomes are essential to transitions - knowing what to reach for and knowing when it’s ok to move on

• Care plans, recovery plans, CPA plans – call them what you like but patients most probably only need one ‘comprehensively simple’ plan

• Successful pathways also need to be clinically efficient. Building a process that takes more clinical time to administrate prolongs journeys rather than shortens them.

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Thank You

keith barry & leigh allen

Government & Nonprofit