Care planning: why, how and the importance of standardisation Suzanne Lucas & Anne Goodchild

Survey: have you ever attended any training for care planning YesNoLearnt about it from others Not sure Qualified clinicians HCA’s Non clinicians

Survey: is care planning part of your routine practice? YesPartiallyNo Qualified clinicians HCAs Question directed: clinicians & HCAs who have experienced care planning training or learnt about it from others

Survey: If no, what were the barriers Barriers

Survey: is care planning part of your routine practice? YesPartiallyNo Qualified clinicians HCAs Question directed: clinicians & HCAs who have not experienced care planning training or learnt about it from others

Survey: If yes, can you describe what you are doing? Examples

Survey: are you aware if care planning is used in your practice? YesNoNot sure Practice managers Other non clincinans Question directed: Practice Managers and other non clinicians

Care planning: why? Meets UK national standards, policy and guidelines: 2014 NHS England Action for Diabetes 2011 NICE Quality Standard 3 ‘people with diabetes participate in annual care planning which leads to documented goals and an action plan’ 2010 DH White Paper there was a commitment to ‘shared decision making’ and ‘choice’ as part of the care planning process 2001 National Service Framework for Diabetes Standard 3 encourages participation in the decision-making process 2008 Darzi High Quality Care for All advocates use of jointly agreed personalised care plans 2006 Department of Health and Diabetes UK provides theoretical basis for care planning Translates into real self care behaviour change Professionals report greater job satisfaction and improved skills and time efficiencies

Care planning: how?

Engaged, informed patient HCP committed to partnership working Organisational processes Commissioning - The foundation Collaborative care planning consultation

“ Agreed & shared care plan ” Information gathering Health Care Assistant or Practice Nurse performs screening tests Sent to patient >1 week before consultation; with agenda setting prompts Prepared nurse / doctor and patient Resultant care plan shared with patient, immediately or by post Information sharing Consultation & joint decision making Year of Care

How Co-Creating Health works

The clinician’s and the patient’s priorities: Voicing both, acknowledging both and then working out what the patient wants to work on, not work on or come back and discuss. HbA1c 68mmol/mol, not picking up prescriptions, not checking blood glucose & on a sulphonylurea Girlfriend has just left, struggling with shift work, forgetting medication, eating “rubbish”, feeling lousy

DMI: three minimum standards Care planning is a way of making sure time spent between patients and healthcare professionals is used in the best possible way, so that when they come together they can; 1. set goals 2. have a record of these 3. follow up and talk about progress

The personal health record

Documenting care planning CARE PLANNING TEMPLATECodes  Goal identification 67L  Identifying barriers to goal achievement 67R  Goal achieved drop down  Goal not achieved 67L0 (zero) 67L1 Follow up arranged drop down  Follow up in 1 month  Follow up in 2-4 months  Follow up in 4-6 months  Follow up in 1 year 8H8 8H87 8H88 8H89 8H8B  Personalised care plan completed 8CMD

What do you think? Please complete the voting paper on your chair What model for Camden? What resources would suit you? Your comments