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The move to personalised care standard operating procedure

Contents

1 Aim

The aim of this standard operating procedure (SOP) is to ensure that all services using patient reported outcome measures (PROMs) and Dialog+ working in Rotherham, Doncaster, and South Humber NHS Foundation Trust (RDaSH) have a full understanding of the processes and procedures to follow. This will ensure a quality service that provides safe and effective personalised care to our patients.

2 Scope

This document will apply to all Rotherham, Doncaster, and South Humber NHS Foundation Trust (RDaSH) services using patient reported outcome measures (PROMs) Dialog or Dialog+, ReQoL-10, goals based outcomes. This includes substantive, temporary and colleagues on honorary contracts of all grades and disciplines including medical colleagues.

3 Link to overarching policy

This procedure is overarched by the following policy, which can be found on the Rotherham, Doncaster and South Humber NHS Foundation Trust policy website.

  • Assessment, care and treatment policy.

The implementation of patient reported outcome measures aligns with the move to a more personalised care approach and the need for high-quality, co-produced, holistic, personalised care and support planning for people with mental health problems living in the community.

4 Procedure

4.1 Definitions, a breakdown of each patient reported outcome measures

Below are some brief definitions of Dialog, Dialog+, ReQoL-10 and goals based outcomes, which will be discussed throughout this SOP.

Dialog, ReQoL-10 and goals based outcomes are a complementary suite of patient reported outcome measures. The suite can be used in isolation or alongside each other as clinically appropriate, however, they are not required to be used all at the same time or in every part of the service, and should be used as clinically appropriate for each service and with individuals as appropriate to their needs. It is good practice for patient answers to be validated within 7 days after a patient reported outcome measure (PROM) is completed as they are measuring the person’s current situation. However, the need to repeat these would this is at the clinician discretion. If no meaningful conversation has been had about the answers then the PROM needs to be completed again.

Dialog is a person-centred patient reported scale of 11 questions. It measures quality of life and ensures practitioners focus on meeting a person’s wider social needs. It can be a useful tool to help facilitate holistic care planning. It consists of a scale of 11 questions which allows a patient to rate their overall quality of life and experience of the care they receive. It identifies a patient reported outcome measure (PROM) on the initial 8 questions on life domains, and a patient reported experience measure (PREM) from the final 3 questions on the treatment they are receiving. It helps structure a person’s care by considering what is important to the person themselves, enabling a holistic and patient-centred approach.

Dialog+ is a full therapeutic intervention using 4-step approach and can form the patient led care plan. Dialog+ has been specifically designed to make routine patient-clinician meetings therapeutically effective and uses a solution-focused approach to understand what is important, look forward and explore the solutions and strengths a person has to achieve their goals. As Dialog+ is patient led, standard clinician led plans of care could still be completed where clinically relevant in addition to Dialog+ to support a patient’s overall care.

The 4-step approach includes:

  1. understanding: reasons for dissatisfaction and what works
  2. looking forward: directing the discussion from the problem to thinking about alternatives and best-case scenarios
  3. exploring options: what can the person do? What can the keyworker or the service they work for do? What can anyone else around them do
  4. agreeing on actions: decision-making and documenting

Further information on care planning from NHS England can be found in section 4.13.

ReQoL-10 provides a better understanding of and measures the factors contributing to personal recovery. It assesses the quality of life for people with different mental health conditions, specifically quality of life, it is an enabling tool for users. It provides a better understanding of and measures the factors contributing to personal recovery. It assesses the connectedness, hope, identity, meaning and empowerment (CHIME) factors for people with different mental health conditions.

Goal based outcomes (GBO) focuses on a patient’s goals and tracks what is the most important thing to measure in any intervention their progress. It is a way of evaluating progress towards goals across all aspects of clinical work. There are no pre-defined questions and up to 3 goals can be recorded. Goal based outcomes was developed from work with children, young people and their families and can be used in any setting that is change-focused and goal-oriented, including adult and physical health contexts. GBO can be used to track progress session by session or as an outcome tool.

4.2 When should patient reported outcome measures be completed

Unless not clinically appropriate, most services should use Dialog as the main patient reported outcome measure to use with patients, with Dialog+ used as the accompanying therapeutic intervention and patient care plan. As Dialog+ is patient led, standard clinician led plans of care could still be completed where clinically relevant in addition to Dialog+ to support a patient’s overall care. Where it has been agreed with the service that Dialog will not be used, ReQoL-10 and goals based outcomes should be completed and reviewed regularly. See section 4.4 for when it may not be clinically appropriate to use the patient reported outcome measures (PROMs).

For services using Dialog, this patient reported outcome measure (PROM) should be completed at the start of a new treatment episode, for example, admission to an inpatient treatment, home treatment service or other community service; referral to new provider organisations to assess a person’s wider needs.

For acute treatment, Dialog should be carried out within 48 hours and in community settings this should be obtained within the first or second meeting. Some patients will be given the opportunity to view and complete a Dialog prior to their first appointment and this can be sent out to the patient if deemed clinically appropriate.

Dialog should be completed every 4 weeks for acute treatment, in inpatients and crisis services and no longer than 6 months for ongoing treatment in community services and other outpatient clinics.

Dialog should be completed at the end of a treatment episode, discharge from a team, service or provider organisation in order to gain a paired outcome and be able to demonstrate a patients increase or decrease in the 11 domains.

More frequent Dialogs should be carried out as clinically required or when carrying out Dialog is clinically indicated. A visual flow chart (staff access only) (opens in new window) of when to use Dialog can be found on the intranet page.

ReQoL-10 can be used for weekly or regular monitoring. It can be used within the session to review progress and be used as a way of identifying areas of collaborative work that would be beneficial to the patient. Two of the questions on ReQoL-10 relating to hope can also lead to risk and safety planning. ReQoL-10 should never be sent out prior to an appointment and should only be completed face to face or via a telephone appointment with a patient.

Goal based outcomes should be used when it is felt that a patient would benefit with setting specific goals to reach as part of their care. These goals should be agreed collaboratively with the patient at the contact, revisited and re-assessed at the next patient contact as appropriate.

The completion of any PROM should be done when there is clinical curiosity around the intervention that has been done together or when there is a significant change in a person’s circumstances. This will enable an understanding if the intervention is working and if there is an increase in a person’s overall quality of life.

4.3 Completing patient reported outcome measures with patients

The complementary suite of patient reported outcome measures should be used with all patients who are able to complete the outcome measures fully. For most services this will consist of Dialog or Dialog+ with ReQoL-10 and (or) goals based outcomes in addition. There is no requirement to use all 3 measures, however, if deemed clinically relevant all outcome measures may be used together. Where patients are unable to complete, colleagues can support, however, the patient should answer the questions in the Dialog scale themselves, without influence from the clinician.

Patient reported outcome measures should be used as part of a meaningful assessment in the move to a more personalised care approach. A meaningful assessment is the capture of any comprehensive assessment that is capable of leading to the start of an intervention or agreeing a co-produced personalised care plan. This could be a patient reported outcome measure (Dialog or Dialog+, ReQoL-10 and goals based outcomes) with a clinician-reported outcome measures (CROM) (supplementary assessment or full needs assessment) if the clinician feels this is clinically appropriate. Ensuring effective assessments is critical to ensuring that individuals are directed to the right support and avoiding delays to waiting times. The meaningful assessment should then lead to the appropriate intervention being identified.

4.4 When patient reported outcome measures may not be clinically appropriate

For Dialog and Dialog+ to be carried out, it is important to determine whether the patient can understand the questions being asked, rather than formally assessing capacity. The decision not to complete a particular patient reported outcome measure (PROM) can be recorded on SystmOne, noting whether this was a clinical or patient decision. Further information on recording this can be found on page 24 of the launch pad guide (opens in new window).

Before carrying out any of the patient reported outcome measures (PROMs) with the people we are working with, we need to assess if it is clinically appropriate or if the person is able  and willing to complete. There are key times when completely a PROM is not clinically appropriate. Here is a list, however not exhausted, of examples where completing may not be indicated:

  • person does not have capacity, they are unable to receive, retain, understand and feedback the information given
  • the person is in a state of shock
  • the person is under the influence of alcohol or substances (nature and degree to consider here)
  • the person lacks insight
  • the person does not want to
  • the person is in a heightened state of emotion such as anger, fear, distress

Dialog may not be meaningful for those with dementia or neurodegenerative disorders, as it was not devised for these diagnoses. Considerations need to be made on diagnosis and services for patients based on a patient’s ability or mental capacity to understand the questions being asked.

It is not appropriate to complete DIALOG with a person that is experiencing delirium because it is not an immediate planning tool. If an existing Dialog is in place, you may see if there are parts that need adapting and can ask questions that are relevant at the time, however you will not need to do the whole PROM for care planning purposes.

ReQoL-10 is not deemed appropriate for children and young people under the age of 16. Dialog has been used with children and young people from age 12 and over.

Where particular outcome measures are not deemed clinically appropriate for specific services within the trust, further work is taking place with these services to move to personalised care in the most appropriate way for their patients. All clinical colleagues, clinical leads and clinical managers should attend the training, irrespective of the use of PROMs with patients on their current caseload or in their current service. Administrative and corporate colleagues who do not provide patient care do not need to attend the training.

4.5 Recording interventions, the community mental health launch pad

The personalised care launch pad (previously called the Community Mental Health Launchpad) should be used to record patient reported outcome measures completed with patients. For community mental health teams, this can be found in the “community launch pad” section of Doncaster, Rotherham and North Lincolnshire Community Mental Health Services. Further work is taking place with specific services to align the above launch pad with their current use of SystmOne including the early intervention “white hand” and the Perinatal “star”.

Detailed information on how to navigate the launch pad can be found in the launch pad guide (staff access only) (opens in new window).

4.6 Use of patient reported outcome measures or Dialog+ in adult community mental health teams

The three recommended patient reported outcome measures (PROMs) (Dialog or Dialog+, ReQoL-10 and goal based outcomes) can be used in all adult community mental health services to enable a shared decision-making process where a patient feels able to focus on what really matters to them. The PROMs should be used as stated in this document in section 4.2 and 4.3 as standard. If it is not deemed clinically appropriate to use with a patient, please see section 4.4.

Using the PROMs in community mental health teams enable a collaborative relationship with a patient, working together towards goals set together and an understanding of progress made towards this.

4.7 Use of patient reported outcome measures or Dialog+ in inpatient settings

Using patient reported outcome measures (PROMs) in an inpatient setting offers opportunities to demonstrate change in outcomes and experiences. Inpatient settings generally result in more disruption for patients than in community teams, therefore more sittings are needed to complete a PROM, meaning that scores will often be taken over time. Clear thinking is needed about iterative filling out of the editable document and how this can properly represent the patient at a given point in time.

One key aim of using the patient reported outcome measures (PROMs) or Dialog+ to achieve true and meaningful co-production within care planning. For the inpatient setting, leave arrangements should be considered as part of this conversation. Patients identify the need for clear signposting of relevant processes and rules, access to decision-makers and understanding of decisions, and patient-led conversations around leave; emphasising the benefits. This aligns with the move to a more personalised care approach, enabling patients to understand how freedom of movement and capacity play a role in recovery and return to the community.

Further information on using Dialog and Dialog+ in an inpatient setting (staff access only) (opens in new window).

4.8 Use of patient reported outcome measures with children’s services

Goal based outcomes was developed from work with children, young people and their families. Simplified versions of goal based outcomes are available for patients from 8 to 13 years and for under 8 years.

Dialog has been used with children and young people from age 12 or older. In this context the job situation question can be replaced with school, education or job depending on the age of the respondent. ReQoL-10 is deemed appropriate for children and young people from the age of 16 or older only.

4.9 Use of patient reported outcome measures with older adults

To ensure Dialog is an appropriate tool for use with some older adults, there may need to be further considerations of the relevance of some of the questions including job situation. There may be some needs that are greater in older adults such as considering loneliness and loss of social networks, grief, loss of autonomy and mobility issues that may impact on the mental and physical health of a person.

Further information on the use of Dialog with older adults (staff access only) (opens in new window).

4.10 Use of patient reported outcome measures or Dialog+ in the primary care mental health hubs

For the use of patient reported outcome measures (PROMs) and Dialog+ within primary care services, please refer to the full primary care standard operating procedure.

For details around the waiting time standard, the clock start and stop and what is required to be completed, please refer to the 4-week wait guidance where you will find supporting documentation and the primary care mental health hub pathway which highlights where the clock starts and stops within the pathway.

4.11 Scoring the patient reported outcome measures

4.11.1 Dialog

The Dialog scale is a set of 11 questions, with a score given by the patient on a scale of 1 to 7 on different elements of a person’s life. Scores should be recorded by the clinician on SystmOne as given by the patient as part of the patient contact.

If the patient has previously completed a Dialog, scores should be compared to make a paired score in order to be able to demonstrate a patients increase or decrease in the 11 domains. These paired scores can be displayed graphically using SystmOne and can show an increase or decrease in the different elements of a patient’s life identified in the questions. These paired scores may represent admission to discharge, admission to review or review to discharge and (rarely) review to review. An increase in the Dialog+ score by 0.25 is evidence of an improvement.

It is important when scoring Dialog that all questions are answered where possible. Where one question score is missing, a mean score can still be calculated and the question missed. However, when more than one question score is missing, mean scores can be substantially affected, and past or future comparisons are prevented.

Scores can be assessed and show the elements of life most affecting the patient’s wellness. Mental health may not always score the lowest, and it is important to identify if other elements need to be addressed with partner organisations and or voluntary sector partners.

For more information on Dialog, please see the animation (opens in new window) and the colleagues leaflet (staff access only) (opens in new window).

4.11.2 ReQoL-10

ReQoL-10 consists of 10 mental health questions and 1 physical health question. Although physical health is important to the quality of life of mental health service users, it is not included in the total score because it is distinct from mental health.

Each question is scored from “none of the time” to “most or all of the time”. The scores are found as a subscript under each response option and are calculated on the system. In the ReQoL-10, there are 6 positively worded questions and 4 negatively worded questions. The positively worded questions are: Q2, Q4, Q5, Q7, Q8 and Q10. They are scored from 0 to 4. The negatively worded questions are: Q1, Q3, Q6 and Q9. The scores are reversed for the negatively worded items which are scored from 4 to 0. An overall index score can be calculated by summing the numbers for the 10 questions. The minimum score is 0 and the maximum is 40, where 0 indicates poorest quality of life and 40 indicates the highest quality of life as measured by ReQoL-10.

If a single question is unanswered, the mean value of the other responses can be used to fill the gap. If more than one question is unanswered, then the overall index score cannot be calculated. If respondents give two answers to a single question, the ReQoL-10 scoring guide (opens in new window) recommends that the lower quality of life response is adopted.

4.11.3 Goal based outcomes

Once a goal has been set, the initial rating for the goal must be set to gain an understanding of where the patient is at that time with the goal. This shows where the patient is starting from, what they have managed to achieve already and track progress at a later date. You could agree with the patient how often you would expect to review progress towards the goal.

Goals can be rated every session using the goal based outcomes (GBO) to track progress throughout an intervention. It may be helpful to compare to the last ratings and discuss with the patient as appropriate. A record of progress can be kept using the GBO goal progress chart. If there is a lack of progress towards goals it can be helpful to revisit.

Goals can change during the course of an intervention and the work should change focus accordingly if this is helpful. Goals may be formally reset and new goals rated. Judgement should be used if to continue rating the old goals.

For further information on goal based outcomes, please see the animation video (opens in new window) and the guidance document (opens in new window).

4.12 The key worker role

The move to personalised care includes alignment to the principals set out in the NHS England position statement (opens in new window), March 2022: “a named key worker for all service users with a clearer multidisciplinary team (MDT) approach to both assess and meet the needs of service users, to reduce the reliance on care-coordinators and to increase resilience in systems of care, allowing all colleagues to make the best use of their skills and qualifications, and drawing on new roles including lived experience roles”.

The key worker would be the person most appropriate person for the patients needs at that time and is not a re-named care coordinator role as identified in the NHS England position statement, March 2022; “Services should not respond to this Statement by simply rebadging care co-ordinators as key workers. The purpose of designating key workers is to ensure that a service user can build a consistent, trusted relationship with an individual who understands their history and who can support the service user to engage with the care and support available through a therapeutic alliance… continuity of care is something that professionals and service users all want to achieve in community mental health services”.

It is likely that Dialog+ would be completed as part of the MDT review where patient reported outcome measures (PROMs) are used with complex patients who would previously have been on the care programme approach (CPA) with multiple clinicians involved in care. In this case, the key worker would be the person deemed most appropriate at that time considering the patients identified requirements. The keyworker role should change over time to ensure the most appropriate person working with that person is right at any time in their treatment journey.

4.12.1 Medical professionals as the key worker

If the medical professional is the only person involved in a patients care, they would default to the patients key worker as they have been deemed the most appropriate person to deliver an intervention. In that case, they would need to review and update the Dialog scale with the patient at the appropriate review point and the Dialog+ would then be completed to decide next steps.

If the medical professional is providing an intervention but are not the patients current key worker, it would need to be agreed who is the most appropriate person to complete a review of the Dialog. However, any change of circumstance for the patient would deem a review necessary and this could therefore be completed by anyone involved in the patients care.

4.13 Care planning

The following statement is from the NHS England Position Statement, March 2022 and identifies the approach to care planning; “In line with the NHS comprehensive model of personalised care, service users should be encouraged to be owners of the information within their care plan, be familiar with its content and feel confident to request reviews and amendments should circumstances change. Care plans should include the actions that the service user undertake, that carers and family members might undertake, and the actions services will undertake to support them. They should include flexible and revisable timescales for review depending on agreement between the multi-disciplinary team, service user and carer or family where appropriate, as opposed to within a long and arbitrary timeframe (currently six or 12 months). Plans should reflect the service user’s individual needs rather than generic service policies or processes. There should be brief, clear documentation and follow-up of agreed actions, given the centrality of trust to any positive therapeutic relationship. In digitised form they should be live, easily available and accessible both in terms of language and format (to service users, carers, family members and all agencies involved in someone’s care), and updated regularly as agreed with the service user. The care planning process and its outputs should be viewed as fundamental parts of the meaningful care that services seek to provide, rather than a box-ticking exercise, and should be linked to routine outcome measurement.” Within the trust, Dialog+ can be used as a care planning tool as part of the move to personalised care.

5 Associated documents and guidance


Document control

  • Version: 1.
  • Unique reference number: 1098.
  • Ratified by: Clinical policy review and approval group.
  • Date ratified: 7 January 2025.
  • Name of originator or author: Senior project manager.
  • Name of responsible individual: Medical director.
  • Date issued: 13 January 2025.
  • Review date: 31 January 2026
  • Target audience: All services using patient reported outcome measures (patient reported outcome measures and Dialog+) with people accessing services.
  • Description of change: New standard operating procedure to support services using patient rated outcome measures and Dialog+.

Page last reviewed: January 30, 2025
Next review due: January 30, 2026

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