This video discusses how, for people with multiple long-term conditions and complex needs, the delivery of integrated care starts with a joint needs assessment and care planning approach. Learn more: [ Ссылка ]
There are two ways to understand the ‘joint’ aspect of these processes - they must be undertaken by a multidisciplinary team and produced with the direct involvement of people who use services and their carers.
Multidisciplinary teams are accountable for joint needs assessment and care planning, while lead assessors ensure the processes used are effective. Well-trained multidisciplinary teams use consistent approaches. Their joint working practices are then able to produce personalised care plans for individuals in their care, with each plan enabling a range of community services to be coordinated, from preventive to urgent care.
The meaningful involvement of individuals and their carers in decisions about care priorities supports person-centred care and better care outcomes, including keeping people at home and out of hospital wherever possible. By taking the service user’s own expectations and capabilities into consideration, the personalisation of care plans supports both social prescribing and self-management.
