Supporting the Individual Journey through Integrated Health and Social Care (Doc)

SUPPORTING THE INDIVIDUAL JOURNEY
THROUGH INTEGRATED HEALTH AND
SOCIAL CARE

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................1
PART A...........................................................................................................................................1
LO 1.................................................................................................................................................1
P1 Outline local resources and provision that supports integrated care working........................1
P2 Describe current local unmet need related to health, care and support service provision in
own locale....................................................................................................................................3
M1 Difference between healthcare and social care providers and types of interagency care
provision in relation to meeting the needs of the individual requiring care................................4
D1 Evaluate local resources and provision to meet needs of individual.....................................5
PART B...........................................................................................................................................5
LO 2.................................................................................................................................................5
P3 Provide support to an individual in a health, care or support service setting.........................5
P4 Role of health, care or support service practitioner in supporting person centred care.........6
M2 Explain own involvement in the different person-centred assessments................................7
D2 Evaluate differences in care assessment................................................................................7
LO 3.................................................................................................................................................8
P5 Provide appropriate leadership within the remit of own role in a health, care or support
service..........................................................................................................................................8
P6 Responsibilities of information sharing between multidisciplinary teams.............................8
M3 Competent and Autonomous Leadership in Information Sharing........................................9
D3 Own personal growth and development................................................................................9
LO 4.................................................................................................................................................9
P7 Different communication methods used to provide appropriate support...............................9
P 8 Apply appropriate communication strategies......................................................................10
M4 Demonstrate safe and clinically effective practice within own professional boundaries. . .10
M5 Analyse own capacity for positive and person- centred risk taking....................................10
D4 Role of Individual to communicate their needs of health care services..............................11
CONCLUSION..............................................................................................................................11
REFERENCES..............................................................................................................................13

INTRODUCTION
Integrated health and social care is defined as the organised set of principles, guidelines
and instructions to provide enhanced levels of patient care with better coordination of services by
the professionals from varied sectors. Integration is the term which infers the combined use of
models, ethics and procedures to maintain cooperation and team work for better services
providers to the patients (Billings and De Weger, 2015). This assignment is based on
understanding the healthcare services in an area where multidisciplinary care is facilitated and is
required on immediate basis. Moreover, this includes a structured overview of Lincolnshire
Community Health Services NHS Trust to understand the gaps that pose as barriers and hamper
the working environment. Additionally, it focuses on the observational methods and role of
support service practitioner in supporting the person centred care. This also emphasis on
different communication methods to understand the significance of transparent channels between
the professional and patient.
PART A
LO 1
P1 Outline local resources and provision that supports integrated care working
Integrated care working aids the medical professional in offering better medical services
to local people. In order to meet the criteria of integrated care working care home is required
financial resources. They need funds so that they can buy new equipment and can offer
satisfactory services to the patients. Furthermore, self-management support is the provision that
need to be implemented in hospital. Social care act 2012 states that local government has to
provide real opportunities to care homes and also they have to monitor their activities timely.
This type of care provisions may help in offering the best services to communities (Carter,
Laurie and Dixon-Woods, 2015). If local hospitals work in collaboration with other health and
social care units then it will help in delivering integrating care to patients. NHS, Local
government association has made it very clear that they will fill the funding gap so that adequate
supply of services can be done.
Higher authorities need to involve more human being such as medical professionals those
who have great experience of offering services to patients. They may provide good and
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immediate care services to service users. They contribution will help in meeting the goal of
integrating care system. Another resource and provision for integrating care working is
collaboration between health care units and other authorities. This collaboration helps in
improving care services and meeting the basic need of local people. Social care institutes for
excellence provides guidelines for making plan and providing quality care to patients.
Emergency care intensive support team (ECIST) have given flow bundle sheet that gives
indicatives to prevent people from longer waiting period. Coalition for collaborative care aids in
working in collaboration with other organization so that person centered care can be provided to
people. Webinar series gives guidelines for organizing improvement programs so that objective
of integrated care setting can be obtained.
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Illustration 1: Mapping of area for identifying services for the chosen organization
(Source: Lincolnshire Community Health Services NHS Trust, 2019)

P2 Describe current local unmet need related to health, care and support service provision in own
locale
An unmet need is refereed as the need that is required to manage the demands or
specifications but have not been fulfilled. In the health and social care sector, unmet needs are
defined as the situational crisis where an individual is devoid of using any health and social care
help and requires the measure the health access (Bupathi and et.al., 2015). Herein, the
Community palliative care in context to the cancer patients has still been considered as an unmet
need which is in the underdevelopment stage. The people with this disease has not been
provided with proper range of services to provide qualitative assistance in giving effective
services. Moreover, it has been demonstrated that the unmet needs are a must in establish better
relations and the organised code of practices to create mutual trust, dignity and respect between
the patients and the professionals.
In regard to the same, it has also been understood that Lincolnshire Community Health
Services is in struggling phase to provide support. Cancer is considered as one of the most
distressing diseases which has not only impacting the physical and psychological aspects of the
affected individuals, but also hampering their social lives due to stigmatised opinions. Thus, this
organization has tried to give practical support for both longer and shorter durations. However,
this is mainly dependent on several demographics factor such as age, physical strength of the
affected individual, emotional support and other practical needs. It is also related to the
population driven and the service driven. Herein the population driven is not possible due to the
interferences from the population and the lack of awareness among the people which focus on
bringing people into health service.
Consequently, the major obstacle that has been outlined is the lack of funding and capital
in regard to the unmet needs. There might be an inappropriate funding allocation that has direct
impact on the working conditions and includes quality and delivery of services does get affected.
It has also included about the need to use the social media to identify the differences between the
quantity and quality aspects of care services (Gulliver and et.al., 2018). Moreover, there is need
to implement the measure the usefulness for such unmet needs which is highlighting the needs of
the patients. The entire objective revolves around ingoing services to the patients in order to deal
with the challenges and several barriers.
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It has been identified that collection the data sources and delegating the works among the
professionals in a team to remove the multimorbity issue. This multimorbidity is related to the
physical, mental and social co-morbiditities. Nevertheless, the specialist care services must
always ensure proper and high levels of improved care services to maintain the patient centred
care (Millá-Perseguer and et.al., 2016). These issues help the professionals to understand the
obstacles and bring some innovative approaches to maintain the gaps by the prevalence of unmet
needs of the people suffering from cancer etc. or require special multi disciplinary group of
prefessionals. Thus, unmet needs are crucial in underlying the necessities of patients in
wholesome manner for overcoming the dilemmas regarding cancer.
M1 Difference between healthcare and social care providers and types of interagency care
provision in relation to meeting the needs of the individual requiring care
There is an interrelationship between the healthcare and social care providers with few
dissimilarities that emphasised on the need to understand in meeting with the specified patient
centred care. There are several principals, code of conduct and work ethics with different
approaches are adopted by both the heath care and social care provides with the common goal of
giving the best treatment and services for faster recovery and management of the entire plan
systematically (Welch and et.al., 2016). Herein, there is a need to understand the basic
modifications between the two for more pronounced levels of professionalism at the workplace,
which paves the path of building up of better relations.
Healthcare provider
The healthcare provider works with different branches of the health care which is consists
of medicine, surgery, dentistry, pharmacy, psychology and nursing facility provided to the
people who needs this kind of service.
Social Care Provider
The social care provider means the person who is providing the services through the
social work, personal care & protection and social support to the people who needs this kind of
services. This kind of services provided to the people who are suffering from poverty and
different disease.
Interagency care
It is a collaboration of different system of care which comes together to provide the
personal and centralized care to the individual. This care services and agencies comes together
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for the solution of individual problem and centralized care of children, adults and old age people
(McKinlay and et.al., 2017). This collaborative approach improves the procedures to provide the
personal and centralized care to the people who need it.
D1 Evaluate local resources and provision to meet needs of individual
It requires huge funds in order to provide high quality service facilities to people. Also,
tools and equipment’s are required to work to provide care services. Besides this, it requires
some provision like proper procedure, guidelines, etc. on how services will be delivered.
PART B
LO 2
P3 Provide support to an individual in a health, care or support service setting
PATIENT'S MEDICAL INFORMATION
Relevant conditions, diagnosis and latest test results:
The patient, Lilly Allen has been diagnosed with leukaemia (blood cancer) and is terminally ill.
She is a 55 years old white female living in the Park Street and is a widow. Her both kids live in
London with their families respectively. Her conditions were evident but at the initial levels,
she ignored the symptoms. She did have a family history and her uncles were diagnosed as well,
yet she did not any pay attention. The conditions were seen with short breathlessness,
complaining of weakness constantly and not able to continue the exercise regime which she has
been following during the week.
The diagnosis included several blood tests and a complete physical examination. This
examination shed light on the tachycardia with an erythematous rash on few sections of her
body, mainly back and abdomen region. In regard to this, the blood tests showed high levels of
white blood cells of approximately 150*109 /L (Normal Range is 4* 109/L to 10*109/L). The
platelet count were below the reference range and was too low of 50*109 /L with low levels of
haemoglobin of 7.3 g/dL. This results were taken two weeks ago and clearly demonstrated that
her conditions are in worsening levels.
Significant past medical history: The patient was not a smoker and never consumed alcohol too.
Moreover, she did get swelling in legs and hands and was unable to breath without assistance.
She was admitted to the hospital and was given a complete check up but nothing abnormalities
was seen. In addition to this, her family did encounter cancer cases and she must have been
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more careful in terms of taking care of her health.
Current medication: Chemotherapy sessions are going on regular basis, however the radiation
therapy is taking additional stress on the body but its necessary to attend it properly. The FDA
approved induction regimes included a 7+3 chemotherapy with infusional cytarabine and
daunorubicin.
Any planned review of medications: When she was diagnosed with anaemia and extreme
leukocytosis, she was given therapy related to overcome the symptoms. Additionally, she is
looking to change her chemo therapy sessions with some organic sessions.
Allergies: No allergies; however, she is uncomfortable with smoking and the pollution it
releases in the surrounding. Sometimes she feels suffocated around the people who are smoking
or whenever she is sitting in such casual places or areas where smoking is allowed.
P4 Role of health, care or support service practitioner in supporting person centred care
There is imperative role of some healthcare and support service practitioners who are
required to provide the multi disciplinary care to the patients. It is important to understand that
such practitioners are beneficial in bringing effective and appropriate support and care services
to manage the well being of patients like Lilly Allen. These are important in imparting education
and providing quality assistance for maintenance of patients in terms of their physical,
emotional, socio-psychological and spiritual care. Such person centred approach helps in
underpinning the entire medical plan to fight against the diseases through well developed and
systematic manner.
Oncologist: He is the specialist who treat patients like Lilly and assist in diagnosis from time to
time. Their expertise is useful in knowing the symptoms beforehand it gets difficult in
controlling the after effects. For instance, Lilly was suggested to undergo MRI on the advice of
this specialist only and later received constructive feedback.
Hemato pathologist: This is that individual who is certified by the Board and is able to take
both examinations such as clinical and anatomical pathology. The major areas for them is to
study the samples of blood, tissue and bone marrow of Lilly Allen.
Radiologist: This individual helps in reading imaging studies through MRI or CT scan. Here,
they helped Lilly in making her understand the prognosis of her conditions. Additionally, the
focus was to make her understand the entire medical procedure.
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Clinical Nurse Specialist: Their contribution is essential in making the patients like Lilly
comfortable by treating them with proper services and complete support. These act as bridge
between the practitioner and the patient. During the specialist sessions and therapy courses, Lilly
was accompanied by nurse which not only boosted her confidence but also assisted her in
gaining knowledge about the leukaemia and its effects properly.
Counsellor: This individual is helpful when the patient is having second doubts about the
medication or any treatment plan. These professionals help in curing cancer psychologically
since there are several prejudiced notions related to cancer. Moreover, they also help the patients
to share their queries through direct channels and mitigate the challenges faced by the doctors or
nurses.
Social Worker: This individual helps the patients like Lilly to propagate about their experience
with other patients and their families suffering from cancer, especially leukaemia. Thus, these are
also supportive to overcome such difficult times.
M2 Explain own involvement in the different person-centred assessments
As a practitioner, I used to define an individual assessment as empowering and
beneficial. In accordance to the case study, I learnt that one must not be negligent and should
follow the guidelines properly to overcome the occurrence of such adverse medical issues.
Furthermore, I also realised that professionals like us must be more approachable and
forthcoming to have an understanding regarding the onset of any sign or symptom related to any
disease. When Lilly felt scared and totally detachable, it was evident that professional help was
needed for her betterment. Thus, I initiated and spoke to her and tried to analyse her inner
feelings. A person centred assessment is a unique concept to bridge the communication gaps and
help the patients to address their queries in direct manner to the associated professionals.
Henceforth, I always look forward in maintaining cordial relations with my patients by giving
them professional advice under ethical standards.
D2 Evaluate differences in care assessment
There are several differences in the integrated care pathway on basis of roles and
responsibilities of professionals. Their roles may vary according to types of care plan and related
treatments which allow them to engage with patients by following their own ethical practices.
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LO 3
P5 Provide appropriate leadership within the remit of own role in a health, care or support
service
Observation write up
There is a great need to promote effective inter professional and multidisciplinary team working
by the professionals to give effectual services and support to the patients. The team members
must approach the autonomous leadership style to bring collaboration and transparency in the
working practices while giving care, support and services to the specific patients (Ben-
Menahem and et.al., 2016.). On personal levels, there is requirement of reliability and mutual
trust to conduct tasks and perform responsibilities to maintain the profitability and productivity
at the workplace. This is possible by discussing the case study from all the aspects and laying
the foundation of proper utilization of allocated resources.
P6 Responsibilities of information sharing between multidisciplinary teams
Date and Time of observation 13th April 2019 at 2:00 p.m.
Rationale This is essential to understand the roles and responsibilities of
each member working in a multi disciplinary team for accurate
and authentic sharing of data, information and details in
context to the patient.
Individual's/Patient's needs The patient is required to undergo proper therapy sessions and
follow the strict compliance of the diet and medication as well.
Additionally, the counselling interactive meetings assisted in
clearing doubts and queries
Details of the setting Lincolnshire Community Health Services NHS Trust where
the individual is meeting the counsellor, radiologist and the
nurse for proper analysis.
Context of the setting To provide complete assistance in terms of support and care
for improving the patient centred care
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Needs and preferences of individuals
These are important for the identification of needs and preferences though care planning and
person centred care among the professionals to provide assistance to the patients in appropriate
modes. Moreover, the patients are mostly prone to more vulnerabilities and find themselves in
between things which leads to lack of clarity and coordination (Reuveni and Vashdi, 2015).
Thus, a competent and autonomous leadership between the inter disciplinary team members in
information sharing is crucial in meeting different individuals’ care needs. This is possible by
restructuring the entire plan according to discussions made and the final outcomes which is
beneficial for the individuals to recover optimum levels of support and quality services.
M3 Competent and Autonomous Leadership in Information Sharing
The observations made during the patient centred care must be identified according to the
results of the conducted tests, exams and related treatments. Herein, the inter disciplinary team
must be in collaboration and support to maintain the quality and delivery of services while
treating patients with special need and attention. In regard to this, the observations must be made
at all the levels to maintain the well being and complete recovery of the affected individuals.
D3 Own personal growth and development
As a health professional the performance can be improved by the implement the health
care facility with full efficiency. The performance of the services is depended on the experience
and professional skills of the healthcare professionals. By conducting different practical and
theoretical training the performance of the individual can be improved. The quality can be
improved by improve the dedication level in the professionals.
LO 4
P7 Different communication methods used to provide appropriate support
There are several communication methods for different individuals to review the care
need by the professionals such as practitioners, nurses, specialists, counsellors etc. It includes
non verbal and verbal type of communication channels to maintain professional interaction with
the patients (Moore and et.al., 2018). Here the non verbal type involves the written
communication channels like emails, text chats, typed electronic documents and reports. This is
more formal approach where the patients' and their families are required to understand each
written word and make decisions accordingly. For instance, report has many technical words and
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thus, they have the basic right to ask questions before taking any treatment or medication. The
verbal type is that type of communication method where direct conversation takes place to
exchange the ideas and opinions without the presence of any physical barriers. These barriers are
more evident in the non verbal type of communication and must be avoided to create any
confusions. Such one to one interactive sessions through conducting seminars or personal
meetings to address the dilemmas, queries and related concepts for maintaining the patient
centred approach.
P 8 Apply appropriate communication strategies
Strategic planning is necessary tool in identifying and responding to the needs of
different service users in a health, care or support services. In regard to the multi disciplinary
team, this is more significant to cover the communication gaps which might affect the quality
services. Here the team members must conduct meetings on regular basis to draw conclusions
and make appropriate treatment plan that suits the needs and requirements for the recovery of the
patients. Along with, there is also need to organize the activities and seminars to improve the
dialogues between the member- member and the patient-member of the heath and social care
services (Wang, Kung and Byrd, 2018). It has been seen that clear and transparent
communication channels would pave the path of mutual respect and dignity to bring
effectiveness in the working practices while giving treatments or check ups.
M4 Demonstrate safe and clinically effective practice within own professional boundaries
As a general practitioner nurse, I always provided my help and support to the colleagues
and members from other areas to curb any challenges that are frequently risen. One of the
effective practices include collaborative approach under the transformational leadership style to
bring productivity at the workplace and maintain the effectiveness in enhanced ways. When
communicating with different service users and staff in health, care or support services, I always
tried to maintain work ethics under the professional levels to produce results in the favour of the
organisation and welfare of the patients. This indirectly help in improving the well being of the
affected patients.
M5 Analyse own capacity for positive and person- centred risk taking
Personally, I felt that I connect with all my patients and try to interact with them to make
them free and open while conversing. Nevertheless, my focus area is to bring constructive
feedback from the patients viewpoints in order to meet with the needs and requirements of the
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ongoing care needs. I have also observed that there are risk attached to the professional works
but with persistence, I support individuals to maintain their identity by being friendly and social
to establish the channels for meeting the ongoing care needs.
D4 Role of Individual to communicate their needs of health care services
By the effective communication personal needs like health care and emotional care can
be evaluated. By showing emotional support and asking about their need can help individual
health professional to find out the need of person. If the patient have trust in health professional
then they will speak out their need.
CONCLUSION
It has been summarised that this assignment is useful in maintaining the supporting
individuals entire journey while implementing the adoption of multi disciplinary team and an
integrated approach. Such outlooks must be in lines with the health and social care of
professionals working to maintain and manage the work ethics. Moreover, this has also described
about the local resources, provision and current local unmet need that supports integrated care
working of the Lincolnshire Community Health Services NHS Trust. This has further
highlighted the need to assess an individual's capacity to recognise the needs and demands
required to fulfil the expectations of the patients. In addition to above, the impact of relationship
with the patient and the multidisciplinary team member is important to adopt for better delivery
of care and health services. Lastly, it explained about different communication methods that are
adopted by the professionals along with application of strategies to respond towards the needs of
each member of inter disciplinary team.
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REFERENCES
Books and Journals
Ben-Menahem, S.M. and et.al., 2016. Coordinating knowledge creation in multidisciplinary
teams: Evidence from early-stage drug discovery. Academy of Management Journal.59(4).
pp.1308-1338.
Billings, J. and De Weger, E., 2015. Contracting for integrated health and social care: a critical
review of four models. Journal of Integrated Care.23(3). pp.153-175.
Bupathi, M. and et.al., 2015. Hepatocellular carcinoma: Where there is unmet need. Molecular
oncology.9(8).pp.1501-1509.
Carter, P., Laurie, G.T. and Dixon-Woods, M., 2015. The social licence for research: why care.
data ran into trouble. Journal of medical ethics.41(5).pp.404-409.
Gulliver, A. and et.al., 2018. An evaluation of a tailored care program for complex and
persistent mental health problems: Partners in Recovery program. Evaluation and
program planning.68.pp.99-107.
McKinlay, E.M.and et.al., 2017. Exploring interprofessional, interagency multimorbidity care:
case study based observational research. Journal of comorbidity.7(1). pp.64-78.
Millá-Perseguer, M. and et.al., 2016. Health-Related Quality of Life of Patients in Primary Care
and Multimorbity. Value in Health.19(7). p.A634.
Moore, P.M. and et.al., 2018. Communication skills training for healthcare professionals
working with people who have cancer. Cochrane Database of Systematic Reviews. (7).
Reuveni, Y. and Vashdi, D.R., 2015. Innovation in multidisciplinary teams: The moderating role
of transformational leadership in the relationship between professional heterogeneity and
shared mental models. European Journal of Work and Organizational Psychology.24(5).
pp.678-692.
Wang, Y., Kung, L. and Byrd, T.A., 2018. Big data analytics: Understanding its capabilities and
potential benefits for healthcare organizations. Technological Forecasting and Social
Chang. 126. pp.3-13.)
Welch, V. and et.al., 2016. Interactive social media interventions to promote health equity: an
overview of reviews. Health promotion and chronic disease prevention in Canada:
research, policy and practice. 36(4). p.63.
Online
Lincolnshire Community Health Services NHS Trust. 2019. [Online]. Avilable
through:<https://www.lincolnshirecommunityhealthservices.nhs.uk/our-services>.
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