Care Planning.. What is it?? Claire Scott Care Planning Lead Berkshire West

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

Engaged empowered patient Organised proactive system Partnership = Better outcomes The evidence base in all long term conditions In England : The Diabetes NSF Internationally: The Chronic Care Model - Wagner

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

Diabetes care plan COPD care plan Arthritis care plan Depression care plan

Your care plan

NWRCCG Practice. Completed training/Action Plan. Templates installed/visit from Claire Scott. Sending Results in advance of consultation Read Codes embedded LTC training COPD/LTC care planning FU Call/visit Balmore ParkSept/Nov 2013 √√√ √ await HCA training05/05/2015 Emmer GreenJan/Mar 2013 √√√? √ phone/ Peppard Rd April/June XXX √ phone/ Priory Avenue April/June √√√√ √ phone/ Circuit LaneMay/Jun 2013 √√√?staffing phone/ Western ElmsOct/Dec 2013 √√√√ √ phone/ Tilehurst SurgeryJan/Mar 2013 √√√√ √ √ yes Mortimer Jan/April 2014 √√√? √ yes/phone/ ThealeOct/Dec 2013√√√? √ yes PangbouneOct/Dec 2013 √√√?Sept yes

SRCCG Practice Training Completed & Action Plan Templates Uploaded (Claire Scott visit) Sending results in advance of consultation. Read Code Embedded LTC Care Planning training COPD/LTC care planning FU visit/ mentoring University Practice√ 08/04/2015 Millman Rd, Lister√√√?√ Yes Milman Rd, Kumar√√√√√ yes Tilehurst Village√√√√x No Melrose, Dr Dean√√√?x no Eldon Rd√√√√√ yes London Rd√√√√√√ No South Reading√√√√√ √ SeptYes Pembroke√√√√√ √ No Whitley Villa√ √√ No Kennet√ √ No London St√√√√√ DSN Chatham St√√√√√ no 79 Russell St√√√√√ √ √ 22/04/2015 Abbey Medical √√√√? yes 41 Russell St Reading Walk-in centre√√√√√ yes Melrose, FAB Williams√√√?? √ yes Longbarn Lane√√√√√ No Shinfield√√√√ √ SeptYes Westwood Rd√√√√√ No Grovelands√√√√√√ 22/04/2015

WCCG Practice Training Completed/Action Plan. Template installed/visit Claire Scott Sending results in advance of consultation. Read Coding embedded. Attended LTC Care Planning training COPD/LTC Care Planning FU visit/mentoring BrooksideJan/Mar 2013√√ √ √ Visit 29/4/15 Burma HillsOct/Dec 2013√√ √X Helen PM called FinchampsteadJan/Mar 2013√√ √X 29/04/2015 Loddon Vale April/June√√ √ √ √ √08/04/2015 New Wokingham Rd Jan/April 2013 √ √ visit 29/4/15 ParksideOct/Dec 2013√√ √√ 22/04/2015 SwallowfieldMay/Jun 2013√√ √ √ Call PM 29/04/15 Wokingham Medical Centre + April/June√√ XX Kate Mansi 26/5/15 10am Twyford Jan/March2014√√ √ √ Kath Miller WargraveSept/Nov 2013X XX Call 29/4 Shar Tanner Wilderness Rd XX XX No Woodley Health CentreMay/Jun 2013X visit,call 29/4, Woosehill K81092Jan 2-14 √√ √√ visit 29/4/15

N&DCCG Practice Completed training/Action Plan Templates uploaded/Claire Scott visit. Sending results advance of consultation. Read Codes Embedded. Attended LTC Care Planning Training. FU Visit COPD/LTC Care Planning Mentoring BurdwoodJan/Mar 2013√√√√ √ √ Yes ThatchamJan/Mar 2013√√√√ √ Yes Chapel Row/BuckleburyJan/Mar 2013√√√√ √ Yes HungerfordJan/Mar 2013√√√√ Yes DownlandJan/April 2013√√√√ Yes KintburyMay/Jun 2013√√√√ Yes NorthcroftMay/Jun 2013√√√√ Yes St Mary's Jan/April 2014√√ √ ? All inclusive √ √ yes need further EastfieldSept/Nov 2013√√ √√ Yes FalklandSept/Nov 2013√√ √√ Yes LambournSept/Nov 2013 √√ √√ √ Yes

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