My Plan – a new meso to micro level building block to promote person-centred care planning

Abstract

Introduction: The Lifetime Care and Support Authority of NSW (LTC) funds the treatment, rehabilitation and care for people severely injured in motor vehicle crashes in New South Wales, Australia. Aligned to best practice and international standards for person-centred integrated care, LTC undertook a major change to the policy, planning and practice approach with those injured (participants in the scheme).Short description of practice change implemented: The revised approach - My Plan, was the major building block to promote person-centred planning and integrated care (1). My Plan enables the funder to ‘hear’ the participant/family’s voice and preferences through self-assessment, participant directed goal setting and prioritisation, monitoring, care plans and service selection. My Plan was developed after extensive research, co-design and piloting. The toolkit includes a suite of modules to support the planning facilitator (case manager) to plan with, and adjust for participant needs at any stage of their lifelong journey. Implementation resources were developed to train and support stakeholders to adopt the change and included internal/external champions, participant/provider on-line resources, eLearning modules, social media community of practice, face to face training, newsletters and meetings. Monitoring and evaluation continues using mixed methods.Aim and theory of change: The aim was to better engage and empower people in the co-creation, integration and management of their cross-sector care, formal and informal supports, thereby enhancing their community participation and wellbeing. We derived seven key principles from broad theoretical concepts, which guided the development and design of My Plan. The concepts were person-centeredness, human rights, social inclusion, health and disability frameworks, integrated care, whole of life approaches, personal and social determinants, strength based approaches for recovery, self-management, supported decision making and evidence based practice.Target population and stakeholders: The initial target population were over 1,000 LTC adult/child participants (and their families) with a complex health condition of: traumatic brain injury, spinal cord injury, amputations, severe burns or blindness.Critical stakeholders were 300 approved planning facilitators (care/case managers), all LTC staff (particularly staff making funding decisions), treatment providers.Timeline: Development and pilot 2013-2015Implementation 2015-2016Monitoring and evaluation 2015 and continuingHighlights: (innovation, impact and outcomes) The monitoring and evaluation data suggests there is a major positive change to perceptions and understanding of participants, and to ways of working by case managers and LTC employees. Importantly participants and families have responded positively to the change with opportunities to co-create, plan, integrate and manage their care.Comments on Sustainability: There has been no significant impact on scheme costs as a result of the changes to planning. The approach and associated toolkit readily lends itself to digital record creation, archiving; individual and population monitoring; is easily shared and can be digitally modified to meet specific needs.Comments on transferability: LTC amalgamated with other groups delivering care to injured people in September 2015 and became icare (Insurance & Care NSW). At meso level My Plan was embedded in the organisation’s policy and systems, with continuing development work with internal staff and external (provider) at micro level practice. The approach has been extended to other parts of the organisation and people with other health conditions (work related injuries, dust diseases). Whilst issues arose with system and legislation differences, My Plan approach appears transferable to other jurisdictions. Anecdotally some case managers from other organisations are using the My Plan toolkit with people who have long term health conditions for care and service planning funded through other public or private sectors.