Quality statement 3: Personalised goals

Quality statement

Adults starting intermediate care discuss and agree personalised goals.

Rationale

Involving people in identifying and agreeing their goals for intermediate care will help to ensure that the care is person-centred and focused on their individual strengths and preferences. Setting personalised goals will also encourage the person to be engaged in their care and promote independence. Personalised goals should be reviewed regularly.

Quality measures

Structure

a) Evidence of local arrangements to ensure that staff carrying out assessments for intermediate care are trained to discuss and agree personalised goals with adults starting the service.

Data source: Local data collection, for example, competency assessments.

b) Evidence of local processes to ensure that personalised goals are documented and shared with the person starting intermediate care, their family and carers (as appropriate), and care staff.

Data source: Local data collection, for example, service protocol.

Process

a) Proportion of adults starting intermediate care who have a record of a discussion to agree personalised goals.

Numerator – the number in the denominator who have a record of a discussion to agree personalised goals.

Denominator – the number of adults starting intermediate care.

Data source: Local data collection, for example, audit of electronic records.

b) Proportion of adults starting intermediate care who have documented personalised goals.

Numerator – the number in the denominator who have documented personalised goals.

Denominator – the number of adults starting intermediate care.

Data source: Local data collection, for example, audit of care plans.

Outcome

a) Satisfaction of adults discharged from intermediate care that the service supported them to achieve their personalised goals.

Data source: Local data collection, for example, survey of adults discharged from intermediate care.

b) Proportion of adults discharged from intermediate care with a level of independence improved from admission.

Data source: Local data collection, for example, audit of electronic records. The NHS Benchmarking Network National Audit of Intermediate Care collects data on dependency levels based on the Modified Barthel Index for bed-based services and the Sunderland Community Scheme for home-based and reablement services.

What the quality statement means for different audiences

Service providers (such as hospitals, community providers, local authorities, care homes, home care agencies and not-for-profit social enterprises) ensure that processes are in place to discuss and agree personalised goals with adults starting intermediate care, and their family and carers as appropriate. Providers ensure that personalised goals are documented and shared with the person, their family and carers as appropriate, and staff providing care. Providers ensure that the care provided supports people to achieve their goals and that their personalised goals are reviewed regularly.

Health and social care practitioners (such as nurses, social workers, allied health professionals, and care staff) ensure that they discuss and agree personalised goals with adults starting intermediate care, and their family and carers as appropriate. They give a copy of the agreed personalised goals, in a suitable format, to the person, their family and carers as appropriate, and staff providing care. Health and social care practitioners ensure that personalised goals are reviewed regularly and that they provide care to support people to achieve their goals.

Commissioners (such as clinical commissioning groups and local authorities) commission intermediate care services that have processes in place to discuss, agree, document and share personalised goals for adults starting to use the service. Commissioners ensure that providers review personalised goals regularly and monitor whether goals are achieved, including levels of dependency, both at the start of the service and on discharge.

Adults starting intermediate care are supported by the care team to plan what they want to achieve – their personalised goals. They are given a copy of their agreed goals in a format that suits them. Agreeing clear goals will help them to work towards improving their independence. Their family and carers may also be involved. Personalised goals should be regularly reviewed.

Source guidance

Intermediate care including reablement (2017) NICE guideline NG74, recommendation 1.5.10

Definitions of terms used in this quality statement

Intermediate care

A range of integrated services that:

  • promote faster recovery from illness

  • prevent unnecessary acute hospital admissions and premature admissions to long-term care

  • support timely discharge from hospital

  • maximise independent living.

Intermediate care services are usually delivered for no longer than 6 weeks and often for as little as 1 to 2 weeks. Four service models of intermediate care are available:

  • bed-based intermediate care

  • crisis response

  • home-based intermediate care

  • reablement.

[NICE's guideline on intermediate care including reablement, terms used in this guideline section]

Personalised goals

Personalised goals to optimise independence and wellbeing should:

  • be based on specific and measurable outcomes

  • take into account the person's health and wellbeing

  • reflect what the intermediate care service is designed to achieve

  • reflect what the person wants to achieve both during the period in intermediate care, and in the longer term

  • take into account how the person is affected by their conditions or experiences

  • take into account the best interests and expressed wishes of the person.

[NICE's guideline on intermediate care including reablement, recommendations 1.1.1 and 1.5.10]

Equality and diversity considerations

Individual cultural and religious needs should be taken into account when discussing and agreeing personalised goals for intermediate care.

Discussions about personalised goals for intermediate care may need to be adapted to meet the needs of people living with cognitive impairment, including dementia, and their family and carers. Healthcare professionals should ensure that the person living with cognitive impairment is supported by a relative or carer or an advocate as appropriate.