Implementing the year of care approach in Leeds Diane Burke – Health improvement Principal Cath Johnson – Head of Nursing Dr Manjit Purewal – Clinical Director and GP

 It is firstly about making routine consultations between clinicians and people with long term conditions truly collaborative, through care- planning - changing the relationship  and then about ensuring that the local services people need to support this are identified and available, through commissioning – changing support for self management NHS Diabetes

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

Hours with healthcare professional = 4 hours in a year Self-management = 8756 hours in a year Long term conditions are different…..

Care planning – it’s a verb! ‘A care plan is at the heart of a partnership approach to care and a central part of effective care management. The process of agreeing a care plan offers people active involvement in deciding, agreeing and owning how their condition is to be managed’ Partnership working

Care plans versus Care planning Having better Conversations

Sent to patient > 1 week before consultation; with agenda setting prompts Prepared HCP and patient Resultant care plan shared with patient, immediately or by post Information sharing Consultation and joint decision making Agreed and shared goals and actions (care plan) 1st visit Between visits 2nd visit HCA performs annual review tests Information gathering

Andrea Mann

Preparing people for care planning

HOW MANY PEOPLE WITH DEMENTIA LIVE WITH AT LEAST WITH ONE OTHER LTC? 90% of people with dementia are living with at least one other long-term condition.

Variations between CCGs are in line with national trend, that areas with higher social deprivation / higher prevalence of long-term conditions, have higher diagnosis rates.

 The percentage of patients diagnosed with dementia whose Care Plan has been reviewed in a face to face review in the preceding 12 months  This can be undertaken holistically using the year of care approach

Enables holistic approach to monitor and review in primary care; Ideally through ‘Year of Care’ approach; Monitoring and review

 We have 8 Year of Care Quality Assured trainers  74 general practices are trained and actively implementing Year of care model  A bespoke clinical template developed to include dementia care planning

 City wide educational events for primary care nurses supported by the memory service  Next steps:  Dementia friends training offered to all practice nurses  Specific training requested – e learning  Shadowing and joint reviews with memory service and practice nurse  Access to ongoing support and guidance from memory service  This work will continue to be driven by the dementia redesign group