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Description
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Enables |
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Shared Care Plans support a Patient-centred approach to care. It allows Health and Care Professionals to view and maintain a single, shared Plan for the Patient/Service User rather than holding separate and disconnected Plans within the individual health and care organisations. It encourages a collaborative approach to supporting Patients/Service Users to meet their health and care needs, including Patients/Service Users with long-term conditions or in residential care. Health or Care Professionals with appropriate access rights involved in delivering care for the Patient/Service User can see and contribute to a Patient/Service User's Care Plan. Guardians, Caregivers with appropriate access rights or the Patient/Service User can also view and update them.
In integrated care settings, all members of the Care Team should have access to the same information and can build upon the Shared Care Plan. Team members act in coordination towards a common goal to provide integrated care and avoid errors. A Shared Care Plan functions as a living document that members of the Care Team refer to or update on an ongoing basis. Service Providers must also be able to seamlessly share and access Shared Care Plans across health or care settings that use different IT systems.
Examples of Care Plans include:
- End of Life Care - contains a Patient/Service User's preferences and wishes for their end of life care
- Urgent Care Plan - contains a Patient/Service User's preferences and wishes in an urgent care setting
- Transitional Care - contains anticipated changes in a Patient/Service User's health status, helping them manage key transition periods in their lives and their care trajectory
- Advanced Care Plan - Following a discussion with the individual about their future wishes and priorities regarding the type of care they would wish to receive and where they wish to be cared for, the plan may be enacted if they lose capacity or are unable to express a preference in the future
- Escalation Plan - contains the support the Patient/Service User would receive in managing potential future events relating to their condition(s). It may cover what to do when Patient/Service User's condition deteriorates and may include instructions for emergency care professionals (e.g. paramedics)
Outcomes
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- I have a better experience as I do not have to repeat my health condition and Shared Care Plan information to different Health or Care Professionals
- I have a say in my health and care plans as I can contribute to the Shared Care Plan and help in setting goals and outcomes that I would like to achieve
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- The sharing of information helps me work collaboratively with other members of the Care Team
- I can make informed decisions as the Patient/Service User’s Shared Care Plan information is shared, up to date and real-time
- I am better informed as have easy access to information about the Patient/Service User, progress of the Shared Care Plan in achieving outcomes and my own work
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- I can make informed decisions for the well-being of the Patient/Service User as I can view up-to-date Shared Care Plan information for the Patient/Service User
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- I am informed and involved as I can view or contribute to the Shared Care Plan of the person I care for
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| titleColor | white |
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| titleBGColor | #183152 |
| title | MUST Epics - Epics and acceptance criteria will be evaluated during the Capability Assessment Stage of Onboarding |
C36E1 - create Shared Care Plan
As a Care Team Member
I want to be able to create Shared Care Plans
So that I can collaborate with other Care Team Members in delivering care to a Patient/Service User
Acceptance criterion 1: Care Team Member creates a Shared Care Plan for the Patient/Service User
Given that the Patient/Service User has been assessed as 'in need of planned care'
And the Care Team Member is permitted to create Shared Care Plans
When the need for a Shared Care Plan is identified for a Patient/Service User
Then the Care Team Member can create a Shared Care Plan for the Patient/Service User
And they can record information relating to the Shared Care Plan
And the Care Plan can be shared with other Care Team Members
C36E2 - view Shared Care Plan
As a Care Team Member
I want to be able to view the Shared Care Plan for a Patient/Service User
So that I can understand the Patient/Service User's Plan and use it to deliver the right care
Acceptance criterion 1: Care Team Member views a Shared Care Plan for the Patient/Service User
Given that the Patient/Service User’s Shared Care Plan has been defined
And the Care Team Member is permitted to view Shared Care Plans
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Health or Care Professionals to manage a single Care Plan for a Patient/Service User which is shared with other Health or Care Professionals. |
Outcomes
For a Patient/Service User: | Provides greater continuity, improved experience and less repetition of information as a result of their health or care information being shared with multiple Health or Care Professionals. |
For a Health or Care Professional: | Enables the ability to work more collaboratively by sharing information with other Health or Care Professionals. This results in more informed decisions based on shared information and an increased ability to deliver more Patient/Service User-based care. |
MUST Epics - Describes the minimum functionality required to deliver a Capability. Solutions MUST be successfully evaluated against each Epic and Acceptance Criteria via Capability Assessment in order to be associated with this Capability |
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E00485 - manage Shared Care PlansAs a Health or Care Professional I want to manage Shared Care Plans for Patients/Service Users So that Shared Care Plans are managed Acceptance criterion 1: create a Shared Care PlanGiven the Health or Care Professional is permitted to manage Shared Care Plans for Patients/Service Users When the Health or Care Professional selects to create a Shared Care Plan for a Patient/Service User Then the Shared Care Plan is created for the Patient/Service User Acceptance criterion 2: view a Shared Care PlanGiven the Health or Care Professional is permitted to manage Shared Care Plans for Patients/Service Users When the Health or Care Professional selects to view a Shared Care Plan Then the Shared Care Plan for the Patient/Service User is displayed |
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Acceptance criterion 3: amend a Shared Care Plan |
As a Care Team Member
Given the Health or Care Professional is permitted to manage Shared Care Plans |
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for Patients/Service Users When the Health or Care Professional selects to amend a Shared Care Plan for a Patient/Service User |
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Then the Shared Care Plan is amended |
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for the Patient/Service User |
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Acceptance criterion 4: close a Shared Care Plan |
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Given the Health or Care |
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Professional is permitted to |
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manage Shared Care |
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Plans for Patients/Service Users When |
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the |
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Then the Shared Care Plan can be amended
C36E4 - close Shared Care Plan
As a Care Team Member
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Health or Care Professional selects to close a Shared Care Plan |
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So that I have an accurate view of active and inactive Shared Care Plans
Acceptance criterion 1: Care Team Member closes the Shared Care Plan
Given that the Patient/Service User’s Shared Care Plan has been defined
And the Care Team Member is permitted to close Shared Care Plans
When it is identified that the Shared Care Plan is no longer needed (e.g. desired outcomes have been achieved or the Patient/Service User no longer needs support)
Then the Shared Care Plan can be closed or made inactive
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| titleColor | white |
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| titleBGColor | #375D81 |
| title | MAY Epics - All May Epics and Acceptance Criteria will be evaluated during the Capability Assessment Stage of On-boarding. However, these Epics are not mandatory and will not be used as part of the overall assessment of whether the Capability is fully met. Any May Epics that are assessed as met will be available to buyers via the Buying Catalogue. |
C36E5 - assign Shared Care Plan actions
As a Care Team Member
I want to be able to assign actions to a member of the Care Team, the Patient/Service User or their Carer and monitor progress
So that I can track progress against the Shared Care Plan and ensure the outcomes are achieved
Acceptance criterion 1: assign action to Care Team Member, Patient/Service User or Carer
Given that the Patient/Service User’s Shared Care Plan has been defined
When an action needs to be assigned to support delivery of the Shared Care Plan for a Patient/Service User
Then actions can be assigned to a member of the Care Team or the Patient/Service User
And progress on actions can be captured or recorded
And progress can be tracked
C36E6 - access Shared Care Plans remotely
As a Care Team Member
I want to be able to access and update Shared Care Plans when I am away from my workstation (e.g. during field visits)
So that I can improve productivity by being able to maintain the Shared Care Plan even when I am working remotely
Acceptance criterion 1: Care Team Members can view and update the Shared Care Plan during field visits
Given that there is a Shared Care Plan for the Patient/Service User
When the Care Team Members is working remotely (e.g. on field visits)
Then they can view the Shared Care Plan
And any updates to the Shared Care Plan can be made
C36E7 - search and view Shared Care Plans
As a Care Team Member
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for a Patient/Service User Then the Shared Care Plan is recorded as closed for the Patient/Service User
E00486 - grant access to Shared Care PlansAs a Health or Care Professional I want to grant access to Shared Care Plans to other Health or Care Professionals So that other Health or Care Professionals can access Shared Care Plans Acceptance criterion 1: grant access to Shared Care PlansGiven the Health or Care Professional is permitted to manage Shared Care Plans for Patients/Service Users When the Health or Care Professional selects to grant access to a Patient/Service User’s Shared Care Plan to another Health or Care Professional Then the other Health or Care Professional can view the Patient/Service User’s Shared Care Plan |
MAY Epics - Describes additional functionality associated with the Capability. Suppliers should consider all MAY Epics as part of their User Research. Suppliers can choose to map their Solutions to these Epics and they will be evaluated via Capability Assessment. Framework Authorities or purchasing organisations may require these Epics as product qualification or requirements criteria |
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E00487 - search for Shared Care PlansAs a Health or Care Professional I want to search for Shared Care Plans for Patients/Service Users using defined criteria So that I can access the relevant Shared Care Plan details Acceptance criterion 1: |
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search for Shared Care PlansGiven the Health or Care Professional is permitted to search for Shared Care Plans |
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When criteria (e.g. Patient/Service User name, type of plan) are used to search for Patients/Service Users or their Shared Care Plans
Then a list of records that match the criteria is displayed
And one or more Shared Care Plans can be selected to be viewed
C36E8 - real-time access to Shared Care Plans
As a Care Team Member
I want to have continuous access to the current version of a Shared Care Plan within its availability target (e.g. 24x7 and 365 days per year)
So that I can make informed decisions for the Patient/Service User based on the most up-to-date information available in the Shared Care Plan
Acceptance criterion 1: Shared Care Plans availability
Given that there is a Shared Care Plan for the Patient/Service User
When the Shared Care Plan is accessed within its availability target period
Then the Shared Care Plan is available to view and / or update
C36E9 - notifications
As a Care Team Member, Patient/Service User or other person who has access to a Shared Care Plan
I want to be able to send and receive notifications in relation to a Shared Care Plan
So that I can ensure that everyone who is involved in the health or care of the Patient/Service User is kept up to date with any changes to the Shared Care Plan
Acceptance criterion 1: send message in relation to Shared Care Plan
Given that the Care Team Member(s), Patient/Service User or other has authorised access to the Shared Care Plan Solution
When they need to communicate with another Care Team Member, the Patient/Service User or their Carer in relation to a Shared Care Plan
Then a message or notification can be sent to one or more recipients
And the message can be read only by the intended recipient(s)
Acceptance criterion 2: receive message in relation to Shared Care Plan
Given that the Care Team Member(s), Patient/Service User or other has authorised access to the Shared Care Plan Solution
When a message or notification is received relating to the Shared Care Plan (e.g. action assigned or change to the Plan)
Then they receive a message or notification
And they can view the message or notification
C36E10 - reports
As a Care Team Member
I want to have access to custom reports relating to the Shared Care Plans for my Patients/Service Users
So that I can use the information to plan my work better
Acceptance criterion 1: Care Team Member views reports
Given that the Care Team Member(s) has access to the Shared Care Plans for one or more Patients/Service Users
And the Care Team Member has access to run reports
When the Care Team Members wants to report on information relating to Shared Care Plans
Then a report can be run to create the relevant output relating to Shared Care Plans
C36E11 - manage Shared Care Plan templates
As a Care Team Member
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When the Health or Care Professional selects to search for Shared Care Plans using defined criteria Then the search results are displayed E00488 - manage Shared Care Plan templatesAs a Health or Care Professional I want to manage Shared Care Plan templates So that I can improve efficiency by using locally defined templates to create Shared Care Plans Acceptance criterion 1: create a Shared Care Plan templateGiven the Health or Care Professional is permitted to manage Shared Care Plan templates When the Health or Care Professional selects to create a Shared Care Plan template Then the Shared Care Plan template is created Acceptance criterion 2: view a Shared Care Plan templateGiven the Health or Care Professional is permitted to manage Shared Care Plan templates When the Health or Care Professional selects to view a Shared Care Plan template Then the Shared Care Plan template is displayed Acceptance criterion 3: amend a Shared Care Plan templateGiven the Health or Care Professional is permitted to manage Shared Care Plan templates When the Health or Care Professional selects to amend a Shared Care Plan template Then the Shared Care Plan template is amended Acceptance criterion 4: delete a Shared Care Plan templateGiven the Health or Care Professional is permitted to manage Shared Care Plan templates When the Health or Care Professional selects to delete a Shared Care Plan template Then the Shared Care Plan template is deleted E00489 - use Supplier implemented Shared Care Plan templatesAs a Health or Care Professional I want to create Shared Care Plans for a Patient/Service User using a Shared Care Plan template created by the Supplier So that I can improve efficiency by using |
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Supplier defined templates to create Shared Care Plans Acceptance criterion 1: |
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use Supplier implemented Shared Care Plan templatesGiven |
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the Health or Care Professional is permitted to manage Shared Care Plans for Patients/Service Users When the Health or Care Professional selects to create a Shared Care Plan |
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for a Patient/Service User |
Then they can access an existing template
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Then they can select to use a Shared Care Plan template provided by the Supplier And the Shared Care Plan is created for the Patient/Service User |
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E00490 - view Shared Care Plan |
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reports |
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As a |
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Health or Care Professional I want to view Shared Care Plan |
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Then the Care Team Member can create, update or delete the relevant Shared Care Plan template
C36E12 - manage care schedules
As a Care Team Member
I want to be able to manage my care schedule
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reports So that reports relating to Shared Care Plans for Patients/Service Users can be viewed Acceptance criterion 1: |
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view Shared Care Plan reportsGiven the Health or Care Professional is permitted to view Shared Care Plan |
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When they need a new or updated care schedule
Then they can create or update a care schedule
And information can be recorded about the planned visit(s)
And the schedule can be shared with other Care Team members and Patients/Service Users as appropriate
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Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability: None |
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Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability: |
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reports When the Health or Care Professional selects to view a Shared Care Plan report Then the report results are displayed |
Items on the Roadmap which impact or relate to this Capability |
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Suppliers will not be assessed or assured on these Roadmap Items as part of Onboarding
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