1

Introduction
The integration of the health and social care subsectors is essential, this is in terms of offering

services for the wellbeing of people and to best meet the rising demand of a growing and aging

population with increasingly complex needs. Therefore, a multidisciplinary approach to care for

individuals stands out to be the best approach as the increasing complexity of patient demands

requires profession input from various disciplines to best provide care. I am currently working

at Concept care solutions a nationwide agency that supplies permanent and temporary

healthcare professionals to other care facilities and authorities. The purpose of the report is

researching on the care services available in my area in meeting the needs of persons needing

multi-disciplinary care and develop a case on an individual who has person-centered plan

towards meeting their social and health needs and it further reflects on my personal

anonymized care assessment and practice in offering care support.

Part-1
LO1 Services of Multidisciplinary care

Integrated care Resources and provisions

Integrated care takes place when health institutions and organizations come together to best

meet the needs of their population, this is sometimes in collaboration with other authorities

and agencies. Integrated care takes on the various forms depending on the circumstances, for

example, it may be centered on primary and secondary care and it may also involve social and

health care (Kane and Luz, 2011). However, a distinction can be drawn between real and virtual

integration where organizations merge their services and where providers work together
 2

through alliances. However, the most ambitious form of integrated care seeks to improve the

health of a population through managing the causes of illnesses and the broader health

determinants. The concept, however, developed in response to the challenges experienced in

the developing countries in the world particularly, the aging population with an increased case

of multiple chronic disease and a variety of behavioral health concerns and the fact that the

increasing needs and demands have not yet been addressed by the increased resources puts

the health systems on a unsustainable strain and equally there is an unacceptable variation in

quality, access, cost and results in their services offered to the patients (Moore and West,

2016). Research has shown that in our local borough there are resources and policies which

support integrated care. The presence of multidisciplinary teams in various care organizations

in the borough and supporting policies and legislation that address chronic illness integrated

action in care organizations.

Unmet needs related to service provision

Health care in its essence is a basic need for all persons unbiased to ethnicity, location, and age.

Health care becomes holistic it is quality and available to all. Research has shown that there is a

great deal of focus on the health and care system in measuring the quality of care being offered

in my local London borough of Barnet. Several reports have been published highlighting the

pressures in community based services that are includes district and social nursing (Olsson et

al., 2019). The research raised some concerns around the changes to the quality and availability

of the services because of the increasing demands and insufficient staff and also funding and

this is attributed to the increasing levels of unmet needs in the borough. However, it was

difficult to defined unmet needs and harder to measure the services. The local authorities in
 3

the Barnet borough need to seek to address the unmet needs for social care. Some of the

identified unmet needs in the borough include the child and adolescent mental health services.

This has been a big need in the borough and the country at large that has not gained much-

needed traction. Statistics show that children and adolescents have experienced an increased

rate of mental illness but the services addressing this cohort has no much support as only one

percent of the entire NHS budget is allocated towards child and adolescent mental health

services as compared to adult mental health services this is important as statistics show that

the population of young people and children in Barnet is estimated to increase by about two

percent between the years 2019 and 2025 (NHS, 2019). According to the hospital admission

records (2019), in the years 2017 and 2018 admissions as a result of self-harm for 10 to 24-year

old’s in Barnet suffer from some type of mental illness Equally, financial constraints have

presented an unmet need in terms of quality of services. The care organizations lack recent

technologies in offering care such as CT scans as they use obsolete technologies due to finical

constraints due to budget cuts.

Difference between health and social care providers

Healthcare and social care needs and providers have for long been confused, with no legally

standing definition for their distinction both the terms have been applied to mean differently in

different situations. However, in the context of NHS consulting healthcare providers is a

company or person that offers healthcare services addressing such a need as treatment,

prevention and control of an illness and the care and aftercare of and individual with such

needs whilst a social care provider is focused on offering support or assistance with activities of

day to day living, maintaining independence, social interaction, assisting patient play a part in
 4

the society, protected them from vulnerable situations and assisting them to manage complex

relationships. Such care provisions must be given consideration to collaboration between

organizations rather than the professionals within them. For instance, looking at the local

authority adult and community services rather than the social workers. In the provision of care,

users of the service may be needing various types of help offered by a range of agencies and

the collaboration between agencies and professionals is essential for a successful care

provision. The interagency collaboration can be on medical equipment, data and research or

professionals.

Resources and provisions locally for care

Evaluation of resources and provisions in the borough evidenced that for an individual requiring

multi-modality treatment is possible for example a patient of cancer will meet with their nurse

navigator and a team of doctors in one visit. The team will be made up of some specialized

doctors in the patients type of cancer which includes a surgeon who is able to order diagnostic

tests do a biopsy to identify if the tumor is malignant or able to operate to remove the cancer if

necessary (Jordan et al., 2010). A medical oncologist who is able to administer immunotherapy

or chemotherapy which kills the cancer cells and a radiation oncologist who can pinpoint where

the cancer is developing and use x-rays to destroy or reduce it. Together the cancer specialist

together with primary care doctors will work with the patient in the development of the most

appropriate and effective plan of treatment for the cancer.

 5

Part-2
Activity 1
Observation Log
Date and time of observation

26th December 2019

Rationale – Given the nature of the patient based off the needs and ailment these

activities were chosen as they best fit the care needs of the patient in terms of making

sure that the patient is able to best continue with their daily activities and be part of

their society regardless of the condition they are in. The activities selected were
The individual’s needs
addressing the individual's needs and wellbeing as they placed the patient at a point of

From the nature of the ailment and the age of the patient, she had unique needs that

were offered for care. Such needs included eating and washing and also grooming,

toileting and administration of medicine. She needed assistance in safe lifting,

transferring, repositioning and locomotion. Emotional support and company and

assistance in performing leisure activities which contributed to her wellbeing.

Details of the setting

The observation was done within the care home, the setting was mainly a care home

setting with other elderly patients being provided care and interacting with their

caregivers.
 6

Describe the context of the setting

In the care home during the observation, various activities were taking place, Other

elderly patients were receiving care from their caregivers while others were just about

minding their duties and leisure activities.

Health Plan
MEDICAL INFORMATION
Recent diagnosis revels heightened blood pressure, especially in the morning when she wakes up.

The patients because of the Ulcer she is advised to avoid foods that are too spicy and beans. She

has recently developed allergies to strong scents and dust casing rampant sneezing and running
Prescription:
nose.

The patient is under Losartan medication for hypertension and Pantoprazole for Peptic Ulcers.

Allergies:

KEY ACTION POINTS

It is recommended that a specific personalized dietary plan that best suits the patients situation and

it is advised that the patients room needs to be sanitized and fumigated to avoid unfamiliar smells

and kept safe form allergies from medications.

ADDITIONAL INFORMATION
 7

Other support services e.g. local authority support, housing

Anticipatory care plan agreed: Anticipatory drugs:

YES YES

Emergency care YES.

Ambulance services – incase of patient experiences blood pressure spike even while on medication

consider ambulance services.

Date of assessment: / Date of review(s):

Special considerations Given the speaking limitation of the patient as a stammer thus, one needs to

be patient when communicating.

Other Consideration

To keep safe from running out of breath the patient needs to lay down on their belly and on a chair.

Case Study-LO2
Identification of personal care needs
Healthcare needs tend to always be different for different people. This deference is come to

because of the different ways people react to various care practices and illnesses. Therefore,

taking this into consideration assists in the diagnosis and selection of care needs. As addressed

by the Mental Capacity Act (2007), which safeguards and promotes decision making within a

legal framework. The act empowers individuals to make decisions for themselves pertaining to
 8

their care when possible and protecting those who have no capacity of making decisions

through offering a flexible framework that places the individuals at the focus of the decision

making. The act is made up of five principles that guide on how the needs and preferences of

individuals are identified (Brooks and Glendinning, 2014). They include principle one a

presumption of capacity where each adult has the right to make their decision and must be

assumed to possess the capacity to do this unless otherwise. Principle two where individuals

need to be supported to be able to make their decisions where they are presented with

assistance to make a decision in terms of presenting to them relevant information. Principe

three where individuals need to maintain their rights to make that which might be viewed as

unwise decisions. Principle four where anything is done for on behalf of an individual needs to

be in within their best interest. Principle five where anything is done for or on behalf of needs

to be without capacity needs to be the least restrictive of their freedoms and rights. Following

these principles, the preferences of the individual can be identified and their needs can be

identified through the diagnosis of their symptoms to identify that which is wrong and once this

is established it will inform what needs to be done to achieve the best results.

Roles in person-cantered care.

As the patient's social care provider my role is to offer more personalized care to the patient. I

am the one to monitor how the patient needs to be taking the prescribed medicine to make

sure that the patient does not skip any prescription which will negatively impact the patient’s

wellbeing (Ekedahl and Wengström, 2018). It is my role to make sure that the patient remains

productive first personally to themselves by making sure that the illness does not limit them

from performing their daily works and basic activities like toileting, taking a bath, eating and
 9

movement. Further, it is within my role to make sure that the patient is emotionally supported

and remains focused on their wellbeing. Primary physicians, on the other hand, have the role of

making sure that the patient's diagnosis is correct and develop a personalized treatment plan

that best fits the patient and prescription of medication to assist the patient to improve their

health status and lifestyle. It is their role to respond to the medical emergency's that befalls the

patient and offer treatment and monitor their wellness process and needs.

Process of person-centred assessments of personal care

Person-cantered care is considered to be a way of thinking and doing things that see individuals

using social and health services as equal parties in developing, planning and monitoring care to

ensure their needs are met. This means pacing the individuals and their keens at the focus of

the decision and viewing them as experts working together for the best results. It is not about

offering people that which they want rather taking into consideration their desires, lifestyle and

values, and circumstances to best develop appropriate solutions. The person cantered

assessments best do to describe the patient in various ways relevant to care provision, for

example, weaknesses and strengths, allergies and physiology, physical and emotional fitness,

sleeping patterns, deficiencies, and needs. Such personal centered details and data presents

necessary and reliable information for the development of a care pathway. The care pathways

will be developed around improving the patients identified weaknesses and complementing

their strengths. It will best describe means of managing deficiencies and inform on the

development of prescription around what the patient is allergic to and need to best help in

making the correct treatment and diagnosis for best care provision.
 10

Capacity assessment to identify improvement areas

The patient’s individual needs can be met in various ways. It is recommended that a meal plan

is developed for the patient. The meal plan will be designed by the doctor it will be developed

around the health needs of the patient to make sure that the patient takes healthy meals that

are assistive in the wellbeing process. Also, a medication timetable is important to make sure

that the medication patterns are followed, this will assist in avoiding any trends in missing

medication which negatively affects the process of wellbeing this is also true for exercise

activities where the patient is scheduled exercises that will assist them in being fit and stay

healthy.

Activity 2
Reflective Report- LO3 and LO4
Relationships within multidisciplinary working
The multidisciplinary team is made up of various parties all form different specializations all

working together for the best diagnosis and treatment of a similar problem. The relationships

within the team are mostly professional (Eklund and Gosman-Hedström, 2010). This is so as all

the team members do their professional task in making sure that the patient is well diagnosed

and present relevant information needed in making the best decision for the patient.

Responsibilities of information sharing

For holistic, reliable and quality care to be achieved for the patient, there is a need for effective

communication and understanding between the members involved in the care of the patient.

The team is made up wholly of the patient and the relevant care professionals (Atwal et al.,

2016). It is the responsibility of the patient at first to honestly provide information to the

practitioner on the symptoms and medical history so that the practitioner is able to diagnose
 11

and identify the patient's ailment. This is essential as sharing of this information is the initial

step to the wellness of the patient if this information is relayed in a manner that some details

are withheld or untrue there is potential for misdiagnosis and maltreatment. Additionally, it is

the responsibility of the nurses, on the other hand, to inform the patient on the progress of

diagnosis and any other relevant information pertaining to the patients health, this is so as it is

within their rights and also for best practice for the patent to be involved in the care process

through giving consent. The care multidisciplinary team are mandated to share all relevant

information good or bad in term of the progress report and share information to the patient on

post-care activities which will enable the patient remain healthy while the care process

continues.

Advantages and disadvantages of information sharing

Information sharing in its essence has its advantages and disadvantages. However, the

advantage or disadvantage is dependent on how the information is shared and perceived.

Within the multidisciplinary team, information sharing has the advantage of early and quick

diagnosis because all relevant and associated information is relayed to the needed party on the

care process. It assists in the easy-care process as members of the multidisciplinary team can

easily; communicate and shear information for the best care process. However, information

sharing sometimes can have its downside mostly towards the patient’s side, it has been

evidenced that sometimes patients get into shock or make ill judgments when bad news or

negative information in relation to their health status is relayed to them out of fear or reaction

(Doyle, 2018). Further incomplete decision making tends to happen when information is too

much, the multidisciplinary teams work best when all relevant parties in the care process
 12

provide only information that is relevant and needed for the care and treatment of the patient.

Too much information opens up windows for indecision and errors as sometimes the

information from the various parties in the team tends to get very ambiguous and may impede

the decision-making process.

Reflecting on my role in the delivery of the care

In partnership with the patient, it was my role to be a social care provider for her. Given her

health condition and age, she was in need of assistance and support in various ways. Observed

it was within my role to make sure that the patient receives care and support in whatever way

she required it while still preserving her independence, rights, freedoms and choices, and a

patient and as a person (Goldman and Reeves, 2019). This called for the ethical practice of my

role and the situation assisted me in developing patients and understanding as I was required

to be patient and always wait on the patient and no matter the situation always be ready and

willing to assist her to be socially connected and be of help to the society. Sometimes the

patient would refuse to take medication and this enabled me to develop effective

communication techniques which enabled me to convince her that it was better for her to take

the medication and get involved in her care process for the best result of treatment and

recovery.

Communication methods used in care delivery

The effective care process by the multidisciplinary team is supported by effective

communication. Various communication methods and techniques are applied to make sure that

the care process is successful. Given the nature of the care is more personal verbal method of

communication was mostly preferred (Gaikwad and Warren, 2019). This is so because this type
 13

of communication tends to best relay information in a manner that both parties can understand

each other and also contribute to the conversation. The communication method is two ways

and therefore, it places the parties at a much better place of expressing themselves. This is

evident when the patient first communicates to the practitioner of her symptoms and diagnosis

is done to identify ailment. This is further, complemented by various communication strategies

employed for best identification and response to the needs of the patient.

Some of the communication strategies applied was asking of questions. Asking questions from

both parties the patient when she needed clarification on procedures and updates from the

care team and from the team when they needed additional information form the patient. This

strategy is effective as it assisted in clarifying one's understanding and also demonstrated

interest in what is being said. Additionally, focusing on the issue, not the person was another

strategy as its not good to the care process become personal rather keep it professional. This

strategy assists in making a distinction over what is required of both parties for the success of

the treatment (Chang and Friedman, 2015). I best demonstrated safe and clinically effective

practice through being ethical by not overstepping and respecting the patients in her desires

and needs and keeping within the boundaries of my role in the multidisciplinary team so as not

to impede another team member's care operation with the patient.

Personal ability to support care.

I believe I am well capable of person-cantered risk-taking in assisting the patient meet her care

needs. I have developed enough knowledge in the field to best understand what needs to be

done and what risks to take in support of the care process. I am capable of keeping to the

schedule and making sure that the patient remains the key focus during the care process and
 14

this is so to make sure that the care process is not disrupted. My interpersonal interactions are

good and I am able to keep and maintain a conversation with the patient and this assists mostly

is offering support to the patient during the social interactions and also in communication as I

am able to best deliver and relay information in a manner that is easy to understand and relate

to.

Own role in delivery of services by communication

In the care process and within the team my duty is considered important. This is because that I

have more access to the patient most of the time compared to the other multidisciplinary team

members and this is essential as I am the first responder to anything that goes on with the

patient. And this connection and interpersonal relationship with the patient presents a humble

platform for the patient to speak up and communicate about any changes in care needs. My

practice in the administration of medication and providing communication support and the

company develops a good relationship where their trust and this presents an opportunity for

holistic care as I will be able to help the patient with issues aside medical treatment as

prescribed but rather personal, emotional and social issues that the patient might be

experiencing.
 15

Conclusion
In conclusion, working at Concept Solutions I understood that the integration of the health and

social care subsectors is essential, this is in terms of offering services for the wellbeing of people

and to best meet the rising demand of a growing and an aging population with increasingly

complex needs. Integrated care takes place when health institutions and organizations come

together to best meet the needs of their local population, research has shown that in our local

borough there are resources and policies which support integrated care. Some of the identified

unmet needs in the borough include the child and adolescent mental health services and

financial constraints have presented an unmet need in terms of quality of services. It is

recommended that the borough employs better strategies and legislation that will address

these unmet challenges.

 16

Reference List
Ekedahl, M. and Wengström, Y., 2018. Coping processes in a multidisciplinary healthcare team–

a comparison of nurses in cancer care and hospital chaplains. European Journal of

Cancer Care, 17(1), pp.42-48

Eklund, K. and Gosman-Hedström, G., 2010. Multidisciplinary team, working with elderly

persons living in the community: a systematic literature review. Scandinavian journal of

occupational therapy, 17(2), pp.101-116.

Goldman, J. and Reeves, S., 2019. Interprofessional collaboration: effects of practice‐based

interventions on professional practice and healthcare outcomes. Cochrane database of

systematic reviews, (3).

Atwal, A., Tattersall, K., Caldwell, K., and Craik, C., 2016. Multidisciplinary perceptions of the

role of nurses and healthcare assistants in the rehabilitation of older adults in acute

health care. Journal of Clinical Nursing, 15(11), pp.1418-1425.

Chang, B.L. and Friedman, C.P., 2015. Consumer health informatics. In Consumer Health

Informatics (pp. 1-7). Springer, New York, NY.

 17

Gaikwad, R. and Warren, J., 2019. The role of home-based information and communications

technology interventions in chronic disease management: a systematic literature

review. Health informatics journal, 15(2), pp.122-146.

Doyle, J., 2018. Barriers and facilitators of multidisciplinary team working: a review. Nursing

Children and Young People, 20(2).

Kane, B. and Luz, S., 2011. Information sharing at multidisciplinary medical team meetings.

Group Decision and Negotiation, 20(4), pp.437-464.

Moore, J. and West, R., 2016. Pathways, networks, and choice in health care. International

Journal of Health Care Quality Assurance, 19(4), pp.316-327.

Olsson, L.E., Hansson, E., Ekman, I. and Karlsson, J., 2019. A cost‐effectiveness study of a

patient‐centered integrated care pathway. Journal of advanced nursing, 65(8), pp.1626-

1635

Brooks, J. and Glendinning, C., 2014. Good practice in social care: the views of people with

severe and complex needs and those who support them. Health & social care in the

community, 22(6), pp.588-597.

Jordan, J.E., Buchbinder, R. and Osborne, R.H., 2010. Conceptualizing health literacy from the

patient perspective. Patient education and counseling, 79(1), pp.36-42.

18