1. SUPPORT FOR PERSONALISED CARE PLANNING IN HEREFORDSHIRE Sarah Caldicott & Karina Blunn Clinical Programme Managers Herefordshire CCG MAY 2015 ‘Putting the patient at the heart of everything we do’ 1

2. What is a Care Plan? An agreement between patients and health or social care professionals to help manage day to day health Based upon what the person needs so that they are in control A document to assess care needed and how this will be provided. Support to manage Long Term Condition through: Setting goals to work towards Support services available – including emergency numbers, such as who to contact with changes in your condition – especially in the event of a change ’out of hours’ Medicines Eating plans/advice and ideas Exercise plans/advice and ideas Paper or electronic? Review of care plan at least once a year – or at times of change May 2015 ‘Putting the patient at the heart of everything we do’ 2

3. May 2015 ‘Putting the patient at the heart of everything we do’ 3 Why undertake Care Planning? To support patient and carer ownership of their care Increase engagement in care, and support self-management Provide information about care and choices/options to inform decision making Take best practice and evidence into practice Enable strategies to be put in place to cope with exacerbations / changes Support annual diabetes health check/review participate to document agreed goals and action plan References: Report from the joint Department of Health and Diabetes UK Care Planning Working Group (Dec 2006) A Year of Care - Partners in Care: A Guide to Implementing a Care Planning Approach to Diabetes Care (Feb 2008)

4. May 2015 ‘Putting the patient at the heart of everything we do’ 4 Diabetes Care Planning NICE Diabetes in Adults Quality Standard - QS6 (2011 At each care planning consultation the healthcare professional(s) gives the patient the opportunity to: share information about issues and concerns share results of biomedical tests discuss the experience of living with diabetes and address needs to manage obesity, food and physical activity receive help to access support and services agree a plan for managing diabetes address individual priorities and goals. identify priorities and/or goals that are jointly agreed including jointly setting a goal for HbA 1c identify detailed specific actions in response to identified priorities which include an agreed timescale

5. Information Prescriptions & Care Planning May 2015 ‘Putting the patient at the heart of everything we do’ 5

6. My Herefordshire Library of Care Plans 06/06/2016 ‘Putting the patient at the heart of everything we do’ 6 Patient held care/self management plan Diabetic hand held record (Disease specific care plan) COPD care bundle (Disease soecific care plan) Anticipatory care plan Social Care assessment Advance decision (directive)

7. Herefordshire Library of Care Plans Patient held care/self-management plans are designed to be the “top layer” in a potential library of care plans. The care plans are designed to support: self-management, sharing information with care providers/contacts, guiding pre-agreed care delivery and direction during a change in a person’s condition. The care plan provides, patients, carers, clinicians, emergency services and others involved in the delivery of individualised care with key information about the person: e.g. Demographic data, including next of kin – personal and professional contacts Details and reference information about an individual’s care journey and needs to support effective care management and delivery for individuals managing and living with a long term condition. May 2015 ‘Putting the patient at the heart of everything we do’ 7

8. Sample original urgent care plan… May 2015 ‘Putting the patient at the heart of everything we do’ 8

9. Sample condition specific care plan May 2015 ‘Putting the patient at the heart of everything we do’ 9

10. Sample anticipatory care plan May 2015 ‘Putting the patient at the heart of everything we do’ 10

11. Breaking News … Health Fabric Potential to use electronic system to support personalised care planning locally in Herefordshire…  https://www.healthfabric.co.uk/ https://www.healthfabric.co.uk/ Mobile application: MyHealthFabric Provides tools to manage healthy lifestyle/s Health Fabric Store works with the app to provide users with a variety of care and self-management plans – local care plans for Herefordshire are being explored May 2015 ‘Putting the patient at the heart of everything we do’ 11

12. Thank you for your time today Are there any questions or comments? May 2015 ‘Putting the patient at the heart of everything we do’ 12

13. Contacts: Karina Blunn & Sarah Caldicott Clinical Programme Managers Herefordshire Clinical Commissioning Group 01432 383779 karina.blunn@herefordshireccg.nhs.ukkarina.blunn@herefordshireccg.nhs.uk, sarah.caldicott@herefordshireccg.nhs.uk sarah.caldicott@herefordshireccg.nhs.uk Herefordshire CCG, Plough Lane, Hereford, HR4 0LE May 2015 ‘Putting the patient at the heart of everything we do’ 13