CHS85 Review and evaluate care management plans with individuals diagnosed with long term conditions

Overview

This standard is about reviewing care management plans with individuals diagnosed with long term conditions and with other healthcare professionals. Care management plans may be developed, reviewed and evaluated in a range of settings including primary or secondary care, a hospital or in the community. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:

1. How to adapt communication styles in ways which are appropriate to different people (e.g. culture, language or special needs)
2. How to establish an understanding of an individual’s values, beliefs and interests
3. The importance of establishing rapport, and how to do so
4. How to ask questions, listen carefully and summarise back
5. How to establish effective communication with and between services providers
6. The principle of confidentiality and what information may be given to whom
7. The importance of involving individuals in discussions, and how to do so
8. The importance of encouraging individuals to ask questions, and how to do so
9. How to effectively negotiate with individuals, families and other professionals
10. The principles of informed consent, and how to obtain informed consent from individuals
11. How to interpret results of baseline observations and tests
12. How to identify deviations and what to do when these occur
13. The individual’s care plan and how it will be managed
14. The importance of identifying the individual’s needs, and how to do so
15. The importance of identifying relevant interventions for an individual, and who can provide them
16. How factors in people’s lifestyles (e.g. physical activity, smoking, diet, alcohol consumption, religious beliefs) can affect their care management plan
17. The importance of reviewing the care plan, and how to do so
18. The criteria for prescribing medications according to national guidelines (e.g. NICE guidelines, SIGN guidelines)
19. Pharmacological therapies for treating individuals with long term conditions and how to determine appropriate therapies
20. Types and methods of taking different medications
21. The effects, side-effects and potential interactions of different medications
22. The effects, side-effects and potential interactions of medication for long term conditions on other health conditions
23. How to undertake a review of medication, including need for changes and possible side effects
24. How to optimise titrations
25. Causes and factors that determine long term conditions and their different stages
26. The short-, medium- and long-term effects of long term conditions on the individual’s physical, psychological, mental and biological states and functions
27. Co-morbidity, and their effects on long term conditions
28. How to communicate with individuals diagnosed with long term conditions
29. The multi-disciplinary team member responsible for each aspect of the individuals’ care plan, and how to contact them
30. The range of tests that may be required when monitoring individuals with long term conditions
31. How to identify deviations from normal states, and what to do about them
32. When to seek advice and refer the individual for further investigations
33. The frequency of monitoring intervals, and how to establish them
34. Organisational guidelines on keeping records and local reporting arrangements
35. Organisational guidelines on the format and frequency of the progress reports from service providers
36. The range of services available locally and nationally for people who need information and support in making and maintain changes in their behaviour, and how to access these services
37. What to do if a need is identified but cannot be met by a service provider
38. Palliative care and end of life care services available locally, and how to access them
39. Your level of authority in optimising care
40. Your level of authority in optimising titrations

Performance Criteria

You must be able to do the following:

1. chase progress reports, if not received from any services and providers, in accordance with organisational guidelines
2. interpret the results of the observations, tests and assessments
3. review all progress reports, including hand-held records maintained by the individual
4. evaluate the effectiveness of interventions and correctly identify when they are not effective in addressing the individual’s needs and meeting prior agreed goals
5. review the individual’s medication, including need for changes and possible side effects
6. seek advice immediately from the relevant member of the individual’s members of the multi-disciplinary team, based on the results of the monitoring or in case of deterioration of individual’s condition
7. refer the individual to the relevant member of the multi-disciplinary team, if necessary
8. renegotiate plans and optimise care and titrations to enable stabilisation and improvement in the individual’s condition, taking into account available services and resources
9. regularly advise and educate other relevant professionals on the individual’s progress and changes in the care management plan
10. provide advice and support to the individual and other people involved in the care management plan
11. recall individuals diagnosed with long term conditions who do not attend monitoring and review sessions
12. make full and concise notes on the individual’s records according to organisational policy

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB6 Assessment and treatment planning This standard has replaced CHD_GB3