P3C-OCT: Person Centred Care Organisational Change Tool · • Other charts later in the Dashboard follow an identical format and scoring mechanism, although the axes have been removed

P3C-OCT: Person Centred CareOrganisational Change Tool:Dashboard of Your Results

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[1] Your Overall Score

[2] Question-by-Question Dashboard

[3] P3C Domains Dashboard

[4] The Full Results1

• The graph above shows your total score on the Person Centred Care Organisational Change Tool (P3C-OCT) in comparison to other practices in the SPQS scheme

• Scores on the P3C-OCT are given out of a total of 20 points• All of the 29 main questions of the OCT are weighted equally, and points are allocated equally for:

• objective activities (e.g. processes you stated you were doing to deliver P3C)• subjective responses (e.g. how well you thought these were working)

• A score of 20 is the theoretical maximum. Such as score is probably not attainable (or desirable), and could only be achieved with: • full P3C activity (as measured by the P3C-OCT)• all activities subjectively rated as “working very well”

• A low relative score does not necessarily indicate poor performance for person centred care – instead, it suggests that other organisations responded more positively to the P3C-OCT, which is likely to be related to factors such as organisational size and structure

• Please see the accompanying “P3C-OCT guide” for further information about the scoring mechanism • Most practices achieve less than half this score, with a median of 6/20*• The score of your practice is highlighted in red, in relation to other practices in blue• Other charts later in the Dashboard follow an identical format and scoring mechanism, although the axes have been removed to

produce minicharts

*In new, complex innovations such as P3C, it would be reasonable to initially expect low scores. We are optimistic that these scores will increase in the future, and that the P3C-OCT will also be sensitive to these changes.

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Your score in comparison to other practices

P3C-OCT Dashboard: Your Overall Score

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The Person Centred Coordinated Care - Organisational Change Tool (P3C-OCT) A brief introduction & quick start guide to the dashboard

• About the P3C-OCT• Person Centred Coordinated Care (“P3C”) is our framework for understanding new models of care, which we define as ‘care

that is guided by and organised effectively around the needs and preferences of individuals with complex needs’. • The P3C-OCT is an evidence based measure of progress towards delivering person centred coordinated care from an

organisational perspective.• This document contains your results from the P3C-OCT, obtained from the answers your organisation gave when responding

to the P3C-OCT.• Your responses are presented in relation to aggregated results from other practices in the SPQS scheme. We believe that

presenting the choices that other organisations have made will help facilitate further improvements in P3C.• These results are purely for feedback, facilitation and learning. They will not be used for auditing and benchmarking

purposes, and will not be shared with anyone else without prior consent.

• Using the P3C-OCT Dashboard• Later in this dashboard, scores for individual questions and domains will be presented in a condensed version of the graph on

the previous page, giving an indication of where your practice is in relation to other practices• The further to the left the orange bar (your practice) is in relation to the other bars, the worse your practice performed in

relation to other practices.• These minigraphs are for indicative purposes only, and are intended to provide an at-a-glance indication of your results.• These minigraphs can help you to identify areas which areas might be particular strengths or weaknesses, although often the

worse performing areas will be factors that are outside of your control (e.g. interoperability and governance; P3C solutions that are not appropriate for your organisational structure)

• Organisation of the P3C-OCT Dashboard• This first section (brown template) provides your overall score and this introductory material .• The second section (blue) gives a question-by-question dashboard of the 29 questions. This contains brief descriptions of the

questions, with minigraphs to help orientate you to the results. • Next, the third section (green) investigates the same data, but instead organises the results according to “domains” of P3C.

In this way, the P3C-OCT is divided and aggregated according to aspects of P3C which are informed by the current policy and research landscape (e.g. National Voices “I” Statements & House of Care), enabling you to interrogate your organisation across these dimensions .

• The final section (black) contains your full results and complete responses, in addition to the aggregate results of the other organisation in the SPQS scheme.

• The P3C-OCT provides a vast wealth of information about what you – and other organisations – are currently striving to do to implement P3C. We encourage taking the time to interrogate the data, paying particular attention to the responses of other organisations in those domains or questions that you wish to improve.

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http://www.nationalvoices.org.uk/publications/our-publications/narrative-person-centred-coordinated-care

https://www.england.nhs.uk/house-of-care/

OCT Results OverviewPart 1: Person-Practitioner InteractionsYour scores in relation to other practices

Link Relative Score Question Summary Link Relative Score Question Summary

Q1Avoiding unnecessary repetition - single contact; plans across/within teams; MDT; discharge

Q7

Eliciting goals

Q2Information to empower people

Q8

Supporting social goals

Q3Prevalence of co-created care plans

Q9aSupport tailored to ability/motivation

Q4

Elements of care plan

Q9bFeedback of PAM scores into practice

Q5Leads for care planning/coordination

Q10Consideration of physical/mental health

Q6Support for Shared Decision Making (SDM)

Q11

Carer support

Hint: these images always link to the start of each section

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OCT Results OverviewPart 2: Practitioner-Practitioner InteractionsYour scores in relation to other practices

Link Relative Score Question Summary

Q12Partnerships with other teams

Q13

MDT Meetings

Q14Allocation of roles/responsibilities

Q15

Who acts on care plans

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OCT Results OverviewPart 3: Organisational Systems & SupportYour scores in relation to other practices

Link Relative Score Question Summary Link Relative Score Question Summary

Q16

Proactive case management

Q22

Caseload assignment

Q17

Measuring experience of care

Q23

P3C training/support

Q18

Allocating P3C to people

Q24

Culture change for P3C

Q19Organising care for those who have P3C

Q25Interventions to reduce hospitalisation

Q20Contacts/appointments for supporting P3C

Q26Polypharmacy/medication review/management

Q21Systems to support/confirm SDM

Q27Other systems to support P3C

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OCT Results OverviewPart 4: Information systems/ IT toolsYour scores in relation to other practices

Link Relative Score Question Summary

Q28

IT systems for self-care

Q29

IT systems in place

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• On the following pages of the dashboard, we breakdown your OCT scores according to six domains of P3C.

• Each P3C domain score has a minigraph for that domain, which is presented in relation to other practices in the SPQS scheme. For scoring and axe of these graphs, please refer to page 2 and the P3C-OCT Guide.

• Below each graph are the P3C-OCT questions that relate to this domain. Clicking on these question numbers will navigate to the results for this question - for both yourself (on the initial question slide) and for other practices (on the subsequent slide).

• On the following slide, we start with your aggregated results for all six of our “Major Domains” of P3C. This is followed by a further six slides with each of the major domains divided into sub-domains

• We recommend that you first identify the domains of P3C which you feel need improving. Next, investigate both the sub-domains and the actual questions that correspond to these domains.

OCT Dashboard: By P3C domains

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Major Domains of P3CYour scores in relation to other practices

My goals Decision Making

Transitions

Care Planning

Information & Communication

Organisational Process Activities

Q2 Q7 Q8 Q9a Q9bQ11 Q28

Q6 Q21 Q1 Q3 Q4 Q5 Q12 Q13 Q14 Q15Q16 Q18 Q19 Q22 Q25 Q29

Q1 Q2 Q5Q12 Q13 Q14

Q1 Q12 Q13 Q14Q15 Q25

Q10 Q17 Q20 Q23Q24 Q26 Q27 Q29

Hint: these boxes are links to explore the sub-domains!

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backGoal Setting: Sub Domains

My goals: Overall Results

Q2 Q7 Q8 Q9aQ9b Q11 Q28

Q7 Q8 Q2 Q9a Q9b Q28

Q2 Q9a Q9b Q28 Q11

My goals: Goal SettingMy goals: Empowerment

& Activation

My goals: Self-Management

My goals: CarerSupport

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backDecision Making: Sub Domains

Q6 Q21 Q6 Q21

Decision Making: Overall Results

Involvement in decision making

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backCare Planning: Sub Domains

Q1 Q3 Q4 Q5 Q12 Q13 Q14 Q15Q16 Q18 Q19 Q22 Q25 Q29

Q3 Q4 Q15 Q29 Q12 Q13 Q14 Q16Q18 Q19 Q22

Q3 Q5 Q12 Q13Q14 Q15 Q29

Q25

Care Planning: Overall Results

The care plan Case management

Single point of contact Care coordination Supporting people to

stay at home

Q1 Q5 Q19 12

backInformation & Communication: Sub Domains

Q1 Q2 Q5Q12 Q13 Q14

Q5 Q14 Q1 Q2 Q12 Q13 Q14

Q1

Information & Communication: Overall

Results

Relational continuityInformation

gathering/sharing

Knowledge of patient/familiarity

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backTransitions: Sub Domains

Q1 Q12 Q13 Q14Q15 Q25

Q1 Q12 Q13 Q14 Q15Q25

Transitions: Overall Results

Continuity of care

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backOrganisational Process Activities: Sub Domains

Q10 Q17 Q20 Q23Q24 Q26 Q27 Q29

Q26 Q23 Q24 Q27Q29

Q20

Organisational Process Activities: Overall Results

Q23

Longer appointment times

Q10

Valuing physical & mental health equally

Q17

Experience of care

Staff trainingProcesses to address

polypharmacyP3C leadership/ culture change

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back P3C-OCT: Full Results of the 29 Questions(a) Your Full Results(b) Aggregated results of all practices

• The final question contains detailed content for each of the 29 main questions in the P3C-OCT.

• On the initial page for each question, we provide your full responses to the P3C-OCT that you previously filled in.

• On the subsequent page, we provide graphs showing the aggregate results of other practices in the SPQS scheme.

• The P3C-OCT is divided into four sections:

• Part 1: Person-Practitioner Interactions

• Part 2: Practitioner-Practitioner Interactions

• Part 3: Organisational Systems & Support

• Part 4: Information systems/IT tools

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back

LEVEL 1: Person-Practitioner interactions Q1: What do you do to ensure that a person doesn't have to repeat themselves unnecessarily? (please indicate which processes you have in place and how well you think they are working)

Possible Options Answers How is this working?

A single person with responsibility for coordinating

all careYes Working well

Sharing a plan of care appropriate information

within your teamYes Working well

Sharing a plan of care appropriate information

across teamsYes Requires some improvement

A shared care plan document within your team Yes Working well

A shared care plan document across teams Yes Requires some improvement

MDT Clinical meetings Yes Working very well

Discharge planning None

Other please specify GP electronic contemporary care record Working very well

• Your Comments: None

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backQ1. Aggregated results of other organisations.

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back

Q2. Which of these is available to empower people?


Providing information sheets Yes Working very well

Signposting to the 3rd sector Yes Working well

Referrals to other services Yes Working very well

Referrals to peer support groups Yes Working well

Pharmaceutical support Yes Working well

Other please specify


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backQ3a. Do all people who could benefit for P3C have a co-created single personalised care plan in the form of a written document? Q3b. Are they given a copy of their care plan?

Possible Options Answers

Within teams A few

Across teams A few

If no why not

3b Are they given a copy of their care plan Yes

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backQ3a & Q3b Aggregated results of other organisations

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backQ4. In general, which of the following elements are included in the co-created plan of care (this can either be in the form of a written document or a plan of working)?


A lead coordinator Yes

A contingency plan for crisis episodes or exacerbations of their condition Yes

A named person to contact in a crisis Yes

An action plan to attain their health goals

An action plan to attain their social goals

Details of who is responsible for what

A List of medications and instructions for when to take

A date for review

Treatment Escalation Plan Yes

None

Not relevant


How well are your care plans working Requires some improvement


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back Q5. Who normally takes the lead for care planning/ care coordination? Please tick as many as appropriate.


Managerial lead

Clinical lead

Team coordinator

GP Yes

District Community Nurse

Community Matron

Community Therapy teams

Social workers

Care workers

None

Not relevant

Other please specity

If dual lead please specify

How well is this working Working very well


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back

Q5. Aggregated results of other organisations.

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back Q6. How is shared decision making with individuals supported in your organisation?


Individual and practitioner work together to set goals Yes

Longer appointment times

Decision aids

Information sheets Yes

Measurements of patient experience of shared decision making

Personal budgets

None Yes

Not relevant


How well is shared decision making working in general in your organisation Requires some improvement

• Your Comments: Currently only benefits a few patients.

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back


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back Q7. How do practitioners specifically elicit goals related to people's health and social aims?


Personalised care plans structured around the

identification of goalsNone Not relevant

Goals prompted in a separate section of the written

personalised care planNone Not relevant

Some practitioners trained to provide guided

conversationsNone Not relevant

Longer appointment times None Not relevant

Using best interest e g Power of Attorney or formal

advocate Yes Working well

Other please specify Not relevant


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back Q8. How do practitioners ensure that people are supported to achieve their individualised social goals?


Conversations with the individual to review goal

achievementYes Working well

The auditing of the plan of care Yes Working well

The use of additional support for example health

trainers peer support coaching advocacy services or

the voluntary sector

Yes Working well

The use of tools to help people track whether they

are achieving their goals for example a diary

checklist charting changes such as weight health

apps

None Not relevant



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back Q9a. How is support tailored to the person's ability and motivation to manage their own health?


Use of a patient measure of activation e g PAM Yes Not relevant

Use of activation measure score as part of the care

planning processNone Not relevant

Health coaching to support self management Yes Working well

Peer to peer support Yes Working well

Group based training for self management Yes Working well

Disease specific training Yes Not relevant

Other please specify Via health connection mendip Not relevant


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backQ9a. Aggregated results of other organisations.

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back

Q9b. How are self-management scores (e.g. PAM) fed back into practice?


Gathered externally and never included in records None Not relevant

Gathered externally and included in records but

rarely usedNone Not relevant

Used informally in care planning None Not relevant

Structured within the care plan None Not relevant



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backQ9b. Aggregated results of other organisations.

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backQ10. In what ways is consideration routinely given to understand how mental wellbeing affects peoples physical conditions, and of the role of physical wellbeing on mental health?


Through Longer appointment times Yes Requires some improvement

Personalised care plans structured to address this None Not relevant

Mental health workers link into the team None Not relevant



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back


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Q11. How are informal carers assessed and offered support?


Identification of the carer population Yes Working very well

Carer health and wellbeing assessment None Not relevant

Providing advice and signposting to support services Yes Working very well

Provision of respite if required None Not relevant



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backLEVEL 2: Practitioner-Practitioner interactions Q12. With what other teams do you have agreements in place to enable partnership working and provide joined up care?


Community based hub or team specialising in LTCs Not Relevant

General practice Yes Working very well

Nursing specialists e g District Nurses Community

Matrons Yes Working well

Mental Health services Yes Requires some improvement

Community Therapy teams Yes Requires significant improvement

Paid care providers e g care agencies Not Relevant

Voluntary sector providers Not Relevant

Social Work teams Not Relevant

Emergency Department Not Relevant

Community based admission avoidance teams Yes Working well

Intermediate care team Not Relevant

Residential care home providers Not Relevant

Other please specify Not Relevant


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back Q13. Do multi-disciplinary team meetings take place to identify the most appropriate services and interventions for people suitable for P3C?

Question Possible Options Answers

Do meetings take place Yes

How often to these MDT meetings happen Monthly


How well are your multi disciplinary team meetings working Requires some improvement

Who attends these meetings Practice nurses Yes

District nurses Community Matrons

Mental health services

Acute care providers

Social workers

Care workers

Voluntary sector e g Age UK

Physiotherapists

Occupational Therapists

Pharmacist

Medical Consultant


None

Not relevant


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backQ14. Are processes in place to allocate roles and responsibilities across and within teams?

Question Possible Options Answers How well is this working?

14 Are processes in place to allocate

roles and responsibilities across and

within teams

Yes

Please identify from below

Processes in place for a single named

person coordinating the support and

care of each person suitable for P3C

WITHIN teams

Yes Working well

Processes in place for a single named

person coordinating the support and

care of each person suitable for P3C

ACROSS teams

Not Relevant

Across team agreements to work

together on a single care planNot Relevant

Processes in place to ensure continuity

of care care transitions please specify

in the comments box below

Yes Not Relevant

Processes in place for active Mental

Health Team inputNot Relevant

None

Not relevant


Comments

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back

Q15. Which practitioners act according to the personalised care plan?


GP Yes

District Community Nurse

Community Matron

Mental Health Team

Social Workers

Care workers e g agency workers

Nominated 3rd sector providers Yes

Physiotherapists

Occupational therapists

Consultant Specialists


Plans are used but not personalised

Plans are not used

Not relevant


How well is this working Working well


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backLevel 3: Organisational Systems and Support: Q16. How do you provide proactive case management (identification, assessment, planning, monitoring and coordination)?


Use of predictive models to identify who will benefit

from P3CYes Working very well

Appointments are available for crisis care Yes Working well

Appointments are available for proactive care Yes Working very well

Multi Disciplinary Team MDT meetings to discuss

complex casesYes Working well

Systematic review of caseload list Yes Working well

Allocation of an individual from MDT with

responsibility to ensure ongoing careNot relevant Not relevant



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back

Q17a. For which groups do you measure the experience of care:


People suitable for P3C None Not relevant

Families of individuals suitable for P3C None Not relevant

Carers of individuals suitable for P3C None Not relevant



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back Q18. What systems are in place to identify and allocate people suitable for P3C?


Risk stratification and automatic allocation None Not relevant

Risk stratification and allocation by team agreement None Not relevant

Agreement by team providing P3C Yes Working well

Routine discharge screening None Not relevant

Ad hoc clinical complexity identified by practitioner Yes Working well

External practitioners services refer in None Not relevant



• 17b. How do you use the measures from Q17a to inform the delivery of care/ support?

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back Q19. Which approaches are used to organise the care of those identified for P3C?


A lead practitioner takes on case management role

for each individualYes Working very well

People s needs and treatment are reviewed regularly Yes Working very well

The need to step up down intensity of input

reviewed regularlyYes Working very well

MDT meetings Yes Working very well

Regular review of case load allocation Yes Working very well



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back Q20. What contact/ appointment arrangements are in place to support P3C?


Appointments specifically for P3C planning None Not relevant

Longer appointments available on request for routine

careNone Not relevant

Home visits for P3C planning Yes Requires some improvement



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back Q21. What systems are in place to support and confirm thatshared decision making has been implemented?

Question Possible Options Answers

21 What systems are in place to support and confirm

that shared decision making has been implemented Care record audit

Using a questionnaire tool to elicit people s

experiences please specify which measure

None Yes

Not relevant


If using a questionnaire tool to elicit people s

experiences please specify which measure

To what degree is this information fed back into

practice Not working

Comments for example which aspects are working

particularly well not well

Ticked not working but above says none so should be

a not relevant to select

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back

Q22. How are caseloads assigned to the following teams?


Nursing specialists None Not Relevant

Mental health services None Not Relevant

Care providers e g agency workers None Not Relevant

Social workers None Not Relevant

Community therapy teams None Not Relevant

Other please specify below None Not Relevant

Name of other team s if any


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back Q23. Are there ongoing efforts to ensure that support and training for staff in P3C continues to be developed in the following areas?

Possible Options Answers How well is this working?

Person centeredness Yes Requires some improvement

Self management None Not Relevant

Empowering and activating individuals to be

involved in self careNone Not Relevant

Coordinating care across teams None Not Relevant

Health coaching None Not Relevant

Shared decision making None Not Relevant

Supporting health promoting behaviours None Not Relevant

Managing polypharmacy None Not Relevant

Decision making in multimorbidity None Not Relevant

Promoting managed risk taking for individuals None Not Relevant


Comments Much of this is normal general practice done by GPs

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back Q24. Which of the following activities/ resources are supporting culture change for P3C?


Change Champions for P3C Yes Requires some improvement

Formal bench marking eg reviewing performance

indicators such as number of personalised care plans

against internal performance or external

organisations

None Not relevant

Informal bench marking eg group reflections on

practice None Not relevant

Auditing P3C activities None Not relevant


• Your Comments: Change Champions for PCCC - improvement = time

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backQ25. What interventions are in place to reduce unplanned or inappropriate emergency admissions?


Predictive modelling to identify people most at risk Yes Requires significant improvement

Support to increase self management skills during

crisis e g medication help seeking Yes Requires some improvement

Telemedicine providing remote clinical services to

patients via communications technologies Yes Requires some improvement

Hospital at home service intensive community based

treatment None

Use of virtual ward None

Coordinated working between health and social care

e g joint assessments None

Ward based health and social care coordinators to

support dischargeNot relevant

Individualised discharge plans Not relevant

Implementation of specialist support Services e g

intermediate complex care teams please specify None

Advanced planning e g Treatment Escalation plans

TEP Lasting Power of Attorney LPA Yes Requires some improvement

Community rehab therapy teams None

Open Ended Response

Type of Specialist support service if applicable

Comments

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back Q26. What procedures are in place to address polypharmacy/ review medication management?


Pharmacist attending MDT meeting Yes Requires some improvement

Pharmacist review for some or all patients Yes Requires some improvement

Questions prompts about medicine taking for

patients during reviewsYes Working well

Routine face to face medicine reviews Yes Requires some improvement

Training for patients in medicine optimisation No Not relevant

Medicine audit Yes Working well



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Q27. What other systems are in place to support P3C?


The pooling of budgets to be used flexibly by teams None

Use of tools and care plans to identify missing

pathwaysNone

Measurement of staff experience of P3C None

Paper based directory of services None



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back

Q28. What kind of promotion is there to support self-care?


Telecare No Not relevant

Telemedicine Yes Requires some improvement

Telecoaching No Not relevant



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backQ29. Which of the following IT based systems are in place?


A template record keeping system to bring together

a single care plan within your teamYes Working very well

A template record keeping system to bring together

a single care plan which is shared across

organisations

None N A

Electronic health social care plans accessible across

team boundaries in real timeNone N A

An electronic directory of services None N A

Individuals routinely have access to care plan

recordsYes Requires some improvement

Individuals can add to their electronic care plan

recordNone N A


Across team agreements to access people s records Across some teams

Across team agreements to add to people s records Across some teams Requires some improvement

Across team agreements to inform others of changes

to people s recordsNone Requires significant improvement

Comments

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Documents

P3C-OCT: Person Centred Care Organisational Change Tool · • Other charts later in the Dashboard follow an identical format and scoring mechanism, although the axes have been removed