Care planning: joined-up thinking

Robert Millett meets physiotherapist Yvonne Cheung and colleagues who coordinate the care of children with complex health, educational and social care needs in north London.

In one of London’s most crowded boroughs a physiotherapist provides coordinated care for children with complex health needs, as part of a pioneering multidisciplinary team. Yvonne Cheung, a band 7 paediatric physio, is part of an innovative integrated care support team (ICST), based in Camden and run by Central and North West London NHS Trust.
As one of three highly specialist clinical assessment and care planning coordinators, she works alongside team leader Hannah Coles, a band 8 speech and language therapist, and Lizzie Mander, a band 7 health visitor and school nurse. The trio’s clinical experience is one factor that sets them apart from similar coordination services, for either adults or children.
‘We are unique in that we are health professionals from different clinical backgrounds, as opposed to an admin team that provides coordination,’ says Ms Cheung. Ms Coles agrees: ‘Traditionally key workers who coordinate care do not have a clinical background, whereas we have extensive clinical knowledge and experience.’ And Mrs Mander points out that ‘the team has funding from the NHS, but most others are council funded’.
Together they oversee the care of children in Camden, from babies up to the age of 18, who require two or more health services, such as paediatrics, occupational therapy, speech and language therapy or physiotherapy. 
In addition, they collate multi-agency plans for the home and educational setting. This can be for children who fall marginally short of the threshold for an education, health and care plan (EHCP), which local authorities draw up for children or young people who have complex educational, health and social care needs. 
The multi-agency plans can also be used to monitor a child’s progress and be used by educational settings as evidence in applying for an EHCP.
With a remit to plan and coordinate assessments and interventions across a range of disciplines and in many environments, the team regularly liaises with colleagues in child and adolescent mental health services (CAMHS) and social care teams. They work with the families of children, their clinicians and school special educational needs and disability coordinators. The aim is to ensure that every child has a personalised care plan that can be followed at home and at school, nursery or other educational settings. ‘We work to bring all the different elements together, so that health, social care and education can become better coordinated,’ says Ms Cheung.

Joined up care

The team was set up in September 2014, following engagement with local parents and carers. ‘Feedback identified that although there were high levels of satisfaction within individual services there was a need for shared care planning,’ Ms Cheung says. Team manager Ms Coles explains that Camden’s community NHS services are provided by four different NHS trusts working in partnership. ‘The Royal Free London NHS Trust provides children’s physios, occupational therapists, special school nurses and paediatricians.  Camden’s speech and language therapists, dieticians, audiology and continuing care are provided by Whittington Health NHS Trust, and CAMHS by Tavistock and Portman NHS Trust. Central and North West London NHS Trust has a coordinating role in the partnership, which includes providing the single electronic patient record and the ICST. It also provides all universal children’s services and MOSAIC, which encompasses specialist health services for children and young people with additional as well as complex needs.
As a result, much of the team’s work involves communicating and sharing information between the borough’s different services and professionals. As well as liaising with external hospitals and specialist services. ‘Our goal is to make things as clear as possible and facilitate clear and understandable communication,’ says Ms Mander. ‘So the job we do is all about creating clarity.’
Each team member has their own caseload, which sees them overseeing the care of 15 to 20 children at any one time. ‘That may include complex cases that need coordination on a daily basis, as well as children who have multidisciplinary care plans in place that just need their progress monitored,’ says  Ms Coles. 
Many referrals come through the service’s single point of referral panel, which is chaired by Ms Coles. This meeting is attended by, the head of the trust’s child development team and the heads of various clinical services, including such as paediatrics, occupational therapy, speech and language therapy and physiotherapy.
An open referral system also allows parents to self-refer, says Ms Cheung, and clinicians who feel that a child’s parents need assistance can refer cases to the ICST. ‘For example, if they are missing lots of appointments then the healthcare professional might discuss the issue with them, ask if they feel they’d benefit from additional support and refer the child to our team,’ she says.
‘We then meet with the family to discuss what they feel they need help with, liaise with the  relevant professionals and then, if needed, pull together a personalised care plan which can be easily managed and monitored.’
The multidisciplinary aspect of their work can create challenges, says Ms Cheung, especially when it comes to coordinating meetings with all the relevant professionals. ‘It can take a long time, because you may need to get 13 different professionals together, which can be time consuming,’ she says. ‘And we need to do that with each individual case, so you can imagine what it’s like when we have 20 cases each.’
On top of these tasks, the team takes a lead in chairing the meetings, taking minutes, following up on action plans and mediating between the families, schools and health professionals. 
‘You are often tested in your conflict resolution and negotiation skills,’ says Ms Cheung. ‘And it can be paperwork heavy, but making sure that the quality of the minutes, goals and plans are of a high standard, saves time in the long-term.’
As well as facilitating communication between all the different parties, the team also strives to offer support to parents, families and/or carers. This can include explaining medical documentation, outlining what they should expect and helping them improve their attendance of hospital or medical appointments. ‘We often have a role in reducing parental anxiety, increasing their confidence and building their resilience,’ Ms Cheung says. ‘That could be to do with helping them understand clinical letters, or figuring out all their different appointments, making a timetable and amalgamating all the information for them.’
As well as their coordination roles, the team members also work clinically on a part-time basis. Ms Cheung works three days a week with the team and works as a paediatric physio on the other two.
‘The children whose care we coordinate have very complex needs and often need to see a physio, nurse or speech and language therapist. We keep all our clinical duties separate, so there’s no overlap, and it doesn’t confuse the families,’ she says.
However, team members feel their clinical experience is crucial. ‘It instils faith in a lot of the parents, because we do know about the clinical pathways and the jargon and how to navigate through the clinical systems,’ says Ms Mander.

Rise in referrals 

Since the service started three years ago the team has received good feedback from both families and professionals, says Ms Coles. One example is a mother who raised a concern two years ago to the clinical commissioning group about a lack of coordination in her son’s care. 
The development of the partnership known as Camden Integrated Children’s Service, which sits within ICST, and the range of improvements this partnership has allowed to develop, has improved care in general, says Ms Coles. ‘This particular child’s mother recently told the team: “The latest appointment with the paediatrician went very well! This is due to the clinician having access to all of his health records; inclusive of all therapy information and a report from an external specialist hospital. This saved time and meant he could get back to school on time for his Friday lunch treat, chips with his friends.”’
And Ms Coles adds: ‘Our referral numbers went up 50 per cent from year one to year two. And we’ve received a lot more referrals from parents this year as opposed to professionals.’
Ms Cheung says one of the best things about her work is seeing a personalised plan come together and developing good relationships with the children, their families and the services and professionals they require. ‘It’s great to see how well multi-agency teams can work when there is good communication,’ she says. 

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Robert Millett

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