Quality statement 3: Coordination of care

Quality statement

Adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care.

Rationale

Managing multiple long-term conditions can be difficult because of the complexity of the conditions and treatment options. An individualised management plan helps ensure that decisions about optimising treatment take account of a person's preferences, needs and priorities; and that the resulting actions are clear. A key aspect is agreement between the person with multimorbidity and the healthcare professional about who is responsible for coordinating care. It is important that the person feels comfortable with the decision and that this information is clearly recorded in the management plan. This can then be shared with healthcare professionals, a partner, family members and carers.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care.

Data source: Local data collection from service specifications.

Process

Proportion of adults with an individualised management plan for multimorbidity whose plan states who is responsible for coordinating their care.

Numerator – the number in the denominator whose individualised management plan states who is responsible for coordinating their care.

Denominator – the number of adults with an individualised management plan for multimorbidity.

Data source: Audit of patient's individualised management plans.

Outcome

a) Number of adults with an individualised management plan for multimorbidity who feel they were involved in the discussion about who is responsible for coordinating their care.

Data source: Patient survey.

b) Number of adults with an individualised management plan for multimorbidity who know which healthcare professional is coordinating their care.

Data source: Patient survey.

What the quality statement means for different audiences

Service providers (such as primary care services) ensure that systems are in place for adults with an individualised management plan for multimorbidity to know who is responsible for coordinating their care, and to record this in the individualised management plan.

Healthcare professionals (such as GPs, practice nurses and practice pharmacists) agree who is responsible for coordinating care with adults with an individualised management plan for multimorbidity. They record this in the management plan, and share the plan with the person and (with the person's permission) other people involved in the care, including other healthcare professionals, a partner, family members and carers.

Commissioners (clinical commissioning groups and NHS England) commission services in which adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care and have this information recorded in the plan.

Adults with a management plan for multimorbidity are involved in deciding who is responsible for coordinating their care. This is recorded in their plan and the plan is given to the person, and if they wish, to family members and carers. Doing this will make sure everyone knows who will organise different parts of the care so that they work well together.

Source guidance

Multimorbidity: clinical assessment and management (2016) NICE guideline NG56, recommendation 1.5.2 and 1.6.17

Definitions of terms used in this quality statement

Individualised management plan for multimorbidity

A plan for a person's care that takes account of multimorbidity based on personalised assessment. The aim is to improve quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care. The plan includes a person's individual needs, preferences for treatments, health priorities and lifestyle. It aims to improve coordination of care across services, particularly if this has become fragmented.

[Adapted from NICE's guideline on multimorbidity]