Requirements and Use Cases

The Digitising Social Care (DiSC) Programme at the NHS Transformation Directorate has launched an Assured Supplier List to support Adult Social Care providers in England to buy from an assured list of Digital Social Care Records (DSCR) Solutions onboarded via the Dynamic Purchasing System (DPS). The requirements in the DPS have been converted into Capabilities and Standards so that they fit the DCS (Digital Care Services) Framework.

The Minimum Operational Dataset is one of these data standards and consists of a list of data classes and data elements, outlining the requirements for how information should be collected from individuals receiving care from a CQC regulated social care service through a digital social care record.

During the development of the MODS, the following use cases / requirements were identified:

Use case 1: Consistency of care to an individual when a temporary worker needs to step in

Scenario:

Mr. Green has been living in a care home for several years. He is a very social person and is often in the communal rooms such as the dining room. Also, he likes to participate in activities such as singing and painting. Mr. Green is somebody who likes to have a lot of structure in his life. He is normally assisted by Nurse Assistant Emily, but she is on leave for a week and her shifts are being covered by an agency worker, Eliza. Eliza is an experienced care worker but has never worked in this care home or met any of the residents. Before starting work this morning she spent a few minutes going over the residents' records to find out a little about them. Today, Mr. Green woke up at 8 o’clock. Nurse assistant Eliza assisted Mr. Green with a shower and helped him to go to the toilet. By himself, he walked to the dining room where he ate two eggs and a roll and drank a cup of coffee. He was sitting next to Mr. Brown where he normally sits. After that, he read the daily newspaper. At 9 o’clock nurse Eva gave him his medication, which he took with a glass of water. At 10 o’clock Mr. Green was picked up by the activity well-being facilitator Mahsa so that Mr. Green could participate in the choir group. He was in a good mood and looked as if he was having a good time with the other residents. At 12 o’clock he went for lunch in the dining room where he ate some soup and a sandwich. After that he went for an afternoon nap in his room.

Goal:

Monitoring the assistance of Mr. Green with his daily life in a care home. Take care of him and help him with washing himself, ensuring he gets his daily medication, food and drinks and that he goes to the activities that he enjoys provided by the care home.

Assumptions:

Retaining patient data roughly consists of three steps: Recording (1), sharing it with colleagues (2) and sharing it with the recipient of care (3). For this process to run smoothly, it is important that the data is understandable and reusable for everyone and can be monitored over time to see changes. In this use case, the focus is on a recipient of care in a care home, so it is information that carers and activity well-being facilitators capture in the daily life of Mr. Green. Every individual and each day are different so the information can be different, it totally depends on the recipient of care and the care needs somebody has at the time. Also, this sharing of information is between carers and activity providers, but it can also be that a transfer message has to be shared multidisciplinary for example between a carer and a doctor. In all situations the information needs to be easily comparable with days, weeks or months before to understand changes in the individual’s state.

Process breakdown

• Note time when Mr. Green was awake and wanted to have a shower (Action, Instruction, activity, action)

• Note which food Mr. Green ate and what he was drinking (Action, Instruction, activity, action)

• Note if and which medication Mr. Green took (Action, Instruction, activity, action)

• Note in which activities Mr. Green was active (Activity, Instruction, activity, action)

• Note which care giver helped the recipient of care (Care Worker, Instruction, activity, action, Care Actor)

• Note how his day schedule looked (Instructions, Activities, Instruction, activity, action)

• Note in which social (group) activities he was active (Activities, Actions, Instruction, activity, action)

• Note how his mood and communication was (Outcome, Observation)

• Note how much sleep he had (Action, Instruction, activity, action)

• Note if any markable changes occurred compared with the situation before (Outcome, Observation)

These data points are the core information about Mr. Green's daily life. MODS contributes to Eliza's ability to care for him and the data she has access to and populates could be recorded using MODS.

Use case 2: Communicating an individual's care needs between local authority and care provider at the point of commissioning

Scenario:

Mr. Bodat is a 73-year-old man, a widower. He was quite healthy till recently but is getting more and more health complaints and social care needs. He lives in a complex home situation. For a week, he cannot not really move due to recent foot problems - he lives on the third floor of an old apartment building with only steep stairs. His days seem to become lonelier and lonelier, and neighbours from downstairs now rarely see him. One neighbour talked to a social care youth worker he met accidentally and mentioned the situation. The youth worker offered to refer Mr. Bodat to Adult Social Care for an assessment of his needs.

Goal:

To assess Mr. Bodat’s eligible care and support needs, and to commission a package of care which will meet those needs and allow him to continue living independently in his own home.

Assumptions:

The system needs to reconcile Mr. Bodat's eligible outcomes, as assessed under the Care Act, with his desired outcomes in terms of his ability to live a fulfilling life. The assessment may identify non-eligible needs which Mr. Bodat nevertheless would like to have met. The care provider and Mr. Bodat may agree on a slightly different set of priorities and outcomes for the care to be provided versus the care funded by the local authority. However, since Mr. Bodat cannot contribute any first-party top-ups to the cost of his care, the costs need to remain within the authority's funding envelope.

Process breakdown

• Youth care worker acknowledges he is not responsible for care, but makes referral to Social Care for assessment. (Request, Correspondence, Administrative Information)

• Emma, a Social Worker, visits Mr. Bodat and carries out a Care Act needs assessment. (Care Needs Assessment, Assessment)

• Emma assesses Mr. Bodat's wellbeing, health, selfcare abilities and social situation, and determines that he is eligible for care to be provided by the local authority. (Assessment)

• Caroline, a finance officer, visits Mr. Bodat to carry out a financial assessment to determine what if anything he will need to pay towards the cost of his care. His income and savings are below the relevant thresholds and the local authority will fund the full cost of meeting his eligible care needs. Caroline also makes an appointment for Mr. Bodat to speak to the Benefits Advice team at the council, as she believes he is eligible for more disability benefits than he is currently receiving due to his declining health. (Assessment)

• In parallel, Emma completes a care plan covering Mr. Bodat's eligible needs. This includes a base unit providing medication reminders and a Lifeline alarm, and two home visits a day to meet his personal care needs. (Care and support plan, Care Plan)
  Emma also puts Mr. Bodat in contact with a community group who offer a befriending service, can help him get online, and can do a weekly shop for him. (Correspondence, Administrative Information)

• Once the care plan has been agreed with Mr Bodat, Emma passes it to the Brokerage team to procure the home care elements.

• The package is picked up by a local provider, who sends Sue to visit Mr. Bodat to get to know him and see what his situation is really like. Sue confirms the information received from the local authority, captures further details of his day-to-day needs, and completes the "About Me" record. (About me, Assessment)

• Sue is able to gauge for herself, as she talks to Mr. Bodat, that the information on the record is accurate in terms of his health, mobility, mental capacity and cognition. (Observation)

• Mr. Bodat tells Sue about his regular medications - although he can administer them himself, he worries about forgetting to take his medication and about getting his repeat prescriptions. (Medication, Instruction, activity, action)

• Sue returns to the office and updates the records. She discusses Mr. Bodat's care needs with her manager and they agree a more detailed care plan showing how his needs will be met within the time funded by the local authority. The manager assigns another worker, Andi, to be Mr. Bodat's care worker. (Care and support plan, Additional support plan, Contingency Plan, Care Plan)

Use case 3: Consistency of care and recording across a multi-disciplinary team

Use case:

Multiple clinicians/professionals/carers involved in an individual's day-to-day life (GP, District Nurse, social worker, care provider, care worker, social prescriber, local authority call handler, others), not operating as part of a multi-disciplinary team, but needing to access clear and accurate records - in a language that bridges the gap between clinical and everyday terminology - and capture/share information to inform ongoing care delivery and to help the person live the life they want to.

Scenario:

• Mrs Smith lives alone but due to mobility issues she is unable to leave her home without support and requires assistance with dressing and personal care. She has dementia so can give inconsistent responses regarding her abilities and medication.

• Jane, an experienced care worker, visits Mrs Smith at 10am. When she arrives she wakes Mrs Smith and administers her medication. Mrs Smith complains of a headache so additional medication is given. Mrs Smith is supported to get out of bed, shower and get dressed. Jane cooks her breakfast and then leaves.

• At midday, Alan, a new social worker, visits to review Mrs Smith's care plan. Mrs Smith's son, Robert, also arrives to take part in this meeting. During the meeting Mrs Smith says that she has no mobility issues and can use the toilet independently. Robert challenges this and explains that Mrs Smith has carers twice a day to help with this. Mrs Smith is confused about her care needs and insists that she does not need support. She also asks for additional medication for a headache. Robert gives her this medication.

• Sophie, a new care worker who has recently joined the agency, arrives to visit Mrs Smith in the evening. When she arrives Mrs Smith advises that she does not need any help going to the toilet and has already taken her medication. Mrs Smith insists that she does not need support so attempts to get to the bathroom by herself and falls.

• Sophie calls an Ambulance as Mrs Smith hits her head when falling and she is taken to A&E. Sophie is unsure what medication Mrs Smith has taken today and the details of her support needs. When Mrs Smith arrives at A&E she tells the doctor and nurses that she lives independently and does not need support with personal care. She also tells them that she has not taken any medication today.

Goal:

Support Mrs Smith to continue to live in her own home by providing consistent care and support. Sharing information with all other professionals and family carers to safeguard and support her, including preventing falls and monitoring medication administered.

Assumptions:

In this use case, the recipient of care lives alone but has dementia so may give inconsistent responses about her care and support needs and medication. Providing clear and consistent information/records about medication administered, Mrs Smith's mobility and personal care needs and the likelihood of confusion due to dementia is essential. This information should be shared with all professionals and family members regularly so they can support Mrs Smith appropriately. If this information is not available to all professionals supporting Mrs Smith, then she may injure herself, receive duplicate medication or overstate her abilities.

Process breakdown

• Note the time Mrs Smith was woken (Action, Outcome, Instruction, activity, action, Observation)

• Note the time Mrs Smith took routine medication (Action, Outcome, Instruction, activity, action, Observation)

• Note the additional medication administered (Action, Outcome, Instruction, activity, action, Observation)

• Note support required for personal care (Needs, Observation, Instruction, activity, action, Care Plan)

• Note food provided (Action, Outcome, Instruction, activity, action, Observation)

• Risk - would additional medication administered by son be captured somewhere that is easily shared with care providers? (Risk, Observation)

• Note fall and procedure followed (Incident, Observation, Instruction, activity, action)

• Hospital admission details (Admission Details, Transfer of Care, Administrative Information)

• Hospital records of medication administered and support required (Medication, Instruction, activity, action)

Use case 4: Providing consistent support in hospital and at home for an individual with an existing care plan

Use case:

Hospital admissions/discharge teams understand the care plan already in place and are able to provide the necessary care information to care providers on discharge

Scenario:

• James has a learning disability and lives in supported living. James has not been well and was admitted to hospital for 48 hours.

• When James arrived with his care worker, they explained to the nurse in A&E that he had a learning disability and would need information explained to him clearly and any documents would need to be in an easy read format. They did not bring along a copy of James' care plan which explains the support he needs with dressing and going to the bathroom etc.

• When James was admitted to the ward, his care worker explained to the ward nurse that he had a learning disability and would need additional support. The carer then had to leave.

• During his stay at hospital James struggled to understand what the doctors and nurses were explaining to him and found it difficult to ask for help. When James was discharged, a different care worker came to collect him, James was very distressed. The nurse gave James' care worker a copy of his discharge papers and explained the extra support and medication James would need over the next week.

• When they arrived home, James' care worker showed the manager his discharge papers and they were filed but the information about James' additional support needs this week were not shared with the rest of the team.

Goal:

Everyone who cares for James in hospital is able to access a digital copy of his care plan so they are aware of his needs and able to provide him with the correct level of support. When he is discharged from hospital, his after care is incorportated into his care plan and the necessary information from his hospital stay is shared with his family carers and care provider staff.

Assumptions:

• As James has a learning disability, he may struggle to understand some of the information provided at the hospital, need extra support and a copy of his care plan should be shared with hospital staff. The Red Bag Scheme could be beneficial in this scenario.

• By having a clear digital shared care record with James's care and support needs available to all NHS staff would enable them to support James better. When he is discharged, the additional support needs from his hospital stay could be added to this digital record and then this could be accessed by all care staff at James' supported living accommodation. This would ensure consistent care and support in both settings.

Process breakdown

• Hospital admission (Admission Details, Transfer of Care, Administrative Information)

• Details of additional support needs noted by nurses - unable to access a digital copy of care plan, no paper copy provided

• Hospital records maintained

• Discharge papers provided to care worker (paper copy)

• Paper copy of the documents filed by the care provider but not shared with all staff who may support James over the next week

Use case 5: Implementing a new social care system

Use case:

Enabling easier implementation of new social care IT systems

Scenario:

• A London council are in the process of implementing a new social care IT system.

• They need to be confident that all potential suppliers have the same understanding of the requirements set out in the tender documentation, so that the tenders they receive are directly comparable and are fit for purpose.

• Each subject of care record needs to capture their demographic information, alerts, care and support needs, family support network, professionals involved etc.

• Then they need to tailor the workflow to meet the needs of their staff for accurate and efficient recording, whilst also capturing all the essential information for statutory returns and future CQC assurance requirements.

• They also need to consider integrations like connected care health systems to ensure they are sharing data securely, in the correct format and regularly to maintain an accurate shared care record.
  To ensure they have captured all of this information, are using the most up to date datasets and terminology, they refer to the DSC Data Catalogue and MODS.

Goal:

• Implement an effective, accurate and efficient social care IT system which meets the needs of their staff, captures all statutory information and promotes effective support and safeguarding of vulnerable adults.

• Implementing a system with standardised datasets and terminology will lead to more effective interoperability between health, social care and care providers.

• Having agreed a MODS, it will make it easier to switch between systems and given agreed areas that should be covered by the MODS should enable system suppliers to have more consistent processes across systems as they all need to meet the same requirements. This should reduce the training overhead for staff and will improve safeguarding as recording standards should be easier to maintain.

Assumptions:

• The LA will have legacy data from whatever system was in use previously. It should be possible for this data to be able to be incorporated into the new system so that there is one case history for each service user. Any previous documents/attachments should be able to be transferred across so that they give the appropriate context to the service user's information.

• It should be possible for information fields to be mapped so that the legacy data can be straightforwardly imported into the new system and will sit under the appropriate headings/sections of that system (e.g. involvements, contact numbers, hazards etc).

Process breakdown

• Procure a social care system that meets the needs of the organisation and supports efficient recording of statutory requirements

• Tailor the system to meet the needs of the staff using the system and the recipients of care

• Consider which data tables are in the system and to which of the MODS do these link

• Import legacy data into the new system and be able to access it (view, edit, update) in the correct screens/areas of that system
  Import any associated documentation or plans into the new system and be able to access them in the appropriate areas of that system

• Work with health and care providers to ensure the systems can integrate

• Provide training to all staff to ensure they can use the system to maintain accurate records

Use case 6: Care provider moving to a digital system

Use case:

As care providers move to digital systems by 2024, enable easier transfer of routine info to local authorities

Scenario:

• A CQC registered care provider is in the process of implementing digital social care records to improve the support they can provider for their recipients of care and their joined up working with other services.
  Utilising the MODS on the DSC Data Catalogue has provided them with guidance around the minimum operational dataset so they are confident that they will meet all statutory/regulatory requirements and the data they will be sharing will be fully aligned with other services. They have then been able to work with the Digitising Social Care Programme to tailor this to their needs and use this opportunity to improve their recording practices.

• By having access to up to date health and social care information, they can create better packages of support for their recipients of care. As a care provider, they have valuable insight into the recipient of care's day to day activities and support needs so they can also share this valuable data with the other services to provide more consistent support in all settings.

Goal:

• The Digitising Social Care Records Programme is aiming for all CQC-registered adult social care providers to have access to a digital social care record that can interoperate with a local Shared Care Record by 2024.

• These records will play an important role in joining up care across social care and the NHS, freeing up time spent by care workers and managers on administrative tasks whilst equipping them with the information they need to deliver care. They are the platform on which other remote care tools can integrate and can enable the greater personalisation of care planning that focuses on the individual.

Assumptions:

• The care provider will have sufficient numbers of networked equipment available (e.g. tablets, pads, laptops etc) for their staff to be able to capture and access key information once that information has been put into a digital system.

• The workforce will be sufficiently trained and IT-capable to be able to access the relevant system(s) to be able to view, edit and update key information on their service users.

Process breakdown

• Procure a digital system that meets the needs of the organisation and supports efficient recording of statutory and regulatory requirements

• Tailor the system to meet the needs of the care provider and residents

• Work with health and social care providers to ensure the systems can integrate

• Provide training to all staff to ensure they can use the system to maintain accurate records

Use case 7: Sharing elements of care planning information across many systems – componentisation of care plan

This use case does not follow the structure of the others, as there are multiple scenarios involved. Instead we have identified a range of user needs which combine to describe the benefits of a properly structured record.

Use case 8: DHSC receiving information from local authorities and care providers

Use case:

DHSC able to receive management information from all local authorities and care providers which uses agreed, understood and shared terminology

Scenario:

• The Department of Health and Social Care (DHSC) are working to improve the way they collect management information from local authorities and care providers. They have noticed that the information they are receiving is often inconsistent and during sessions to analyse the data with local authorities and care providers they discussed the data discrepancies. This highlighted different understanding of the terms being used. Some terms were used differently by local authorities and care providers, for example 'carer' and other terms like 'personal budget' had varying definitions.

• A glossary of adult social care terminology with agreed definitions would help to resolve this issue and provide more consistent data for DHSC.

Goal:

• DHSC receive management information in a consistent format with agreed and understood terminology to ensure information is reported consistently. To do this, an agreed glossary of terms and definitions should be created in partnership with health, care providers and local authorities.

Assumptions:

• Throughout the discovery phase of this project we have identified a number of words/terms that are used inconsistently by different services or have multiple meanings. Finding consistent definitions can be difficult and often each authority has a slightly different definitions for a term, a good example is personal budget. Having a defined and consistent terminology that all local authorities and care providers use would reduce the confusion and inconsistency.

Additional use cases, prioritised and mapped to care actors: