1. Shared Decision Making, Self Care, Personalised Care Planning and IT: A Direction of Travel Diabetes Sian Finn Self Care Programmes Manager NHS Worcestershire

2. It is impossible not to manage one’s health. The only question is how one manages. Lorig and Holman 2003

3. White Paper : Liberating the NHS Shared decision-making will become the norm: ‘no decision about me, without me’ Put patients in charge of decisions about their care, giving control of health records

4. NHS Operating Framework 2011-12 PCTs should develop and implement plans for shared decision making and information giving and should include these areas in contracts. PCTs should also publish, via Your Guide or similar mechanisms, an account of how they have delivered shared decision making and information giving. Patient experience must be a key arbiter of all NHS services

5. National QIPP LTC Workstream Based on 4 Key Principles Commissioners understanding the needs of their population and managing those at risk to prevent disease progression Empowering patients to maximise self-management including ensuring patients have a care plan and appropriate information and knowledge about how to manage their condition. Providing joined up and personal services particularly in community and primary care and working closely and effectively with social care Strong professional and clinical leadership and workforce development

6. Alf Collins Co- Creating Health presentation and QIPP Webex November 2010

7. Alf Collins QIPP LTC Ignition Phase Self Care Presentation 2010

8. Alf Collins Co-creating Health presentation and QIPP Webex November 2010

9. Activation is Developmental Activation is Developmental Source: J.Hibbard, University of Oregon

10. Activating Interventions System Interventions Patient held records Patient access to records Results sharing Agenda setting sheets Access to information Self management programmes Clinician Interventions Negotiated agenda setting Shared information Supported goal setting Supported problem solving Follow up on goals Alf Collins Co-creating Health presentation and QIPP Webex November 2010

11. Personalised Care Planning and Self Care Personalised care planning and self care work together as part of one process of care delivery that promotes patient empowerment and choice, supporting people to be more independent and in control of their conditions and to become more actively engaged. Improving the health and well being of people with long term conditions, DH January 2010

12. Key Objectives for Commissioners Work with providers to ensure that : They are offering personalised care planning as part of the service, care pathway and /or models of care for people with long term conditions Services to support self care and structured education are incorporated into local care pathways as routine and that they are specifically linked to care planning Commissioning Personalised Care Planning: A Guide for Commissioners (DH 2009)

13. What is Personalised Care Planning? Personalised and integrated care planning is essentially about: Addressing an individual’s full range of needs, taking into account their health, personal, family, social, economic, educational, mental health, ethnic and cultural background and circumstances. A holistic process, seeing the person ‘in the round’ A strong focus on helping people together with their carers to achieve the outcomes they want for themselves, for example to live independently, achieve at school or return to work. Providing people with quality, timely and relevant information, self care and self management advice. Risk management and crisis and contingency planning are integral to the process, in particular for people with complex needs or for those approaching the end of life

15. Stakeholders in Personalised Care Planning Patients Clinicians Commissioners

17. Personalised Care Planning: What is it?

18. Personalised Care Planning Linking care planning and commissioning MENU OF OPTIONS (menu set by commissioner in collaboration with providers) Education Weight management Screening for complications Telephone review Smoking cessation advice Local authority exercise programme Specific problem solving EPP etc… Individual patient choices via the care planning process = micro-level commissioning Macro-level commissioning by the commissioner (PCT/practice) on behalf of the whole LTC population

19. Improving Care for People with Long Term Conditions: 'at a glance' information sheets for healthcare professionals, DH (2011) Download Information sheet 1: Personalised care planning, gateway ref: 15058 (PDF, 170K)Download Information sheet 1: Personalised care planning, gateway ref: 15058 (PDF, 170K) Download Information sheet 2: Personalised care planning diagram, gateway ref: 15080 (PDF, 219K)Download Information sheet 2: Personalised care planning diagram, gateway ref: 15080 (PDF, 219K) Download Information sheet 3: Care coordination, gateway ref: 15058 (PDF, 145K)Download Information sheet 3: Care coordination, gateway ref: 15058 (PDF, 145K) Download Information sheet 4: Assessment of need and managing risk, gateway ref: 15330 (PDF, 173K)Download Information sheet 4: Assessment of need and managing risk, gateway ref: 15330 (PDF, 173K) Download Information sheet 5: What motivates people to self care, gateway ref: 15347 (PDF, 180K)Download Information sheet 5: What motivates people to self care, gateway ref: 15347 (PDF, 180K) Download Information sheet 6: Goal setting and action planning, gateway ref: 15438 (PDF, 200K)Download Information sheet 6: Goal setting and action planning, gateway ref: 15438 (PDF, 200K) Download Information sheet 7: How information supports personalised care planning and self care, gateway ref: 15331 (PDF, 205K)Download Information sheet 7: How information supports personalised care planning and self care, gateway ref: 15331 (PDF, 205K) Download Information sheet 8: End of life care and personalised care planning, gateway ref: 15350 (PDF, 188KDownload Information sheet 8: End of life care and personalised care planning, gateway ref: 15350 (PDF, 188K

20. NHS Operating Framework 2011-12 PCTs should be commissioning the relevant structured patient education to support people newly diagnosed with diabetes and at appropriate points in their life as their condition progresses

21. NICE Draft Quality Standards for Adults with Diabetes People with diabetes participate in an annual care planning review which leads to agreed and documented goals and an action plan. People with diabetes and/or their carer(s) receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing reinforcement.

22. Worcestershire PCT: QOF DM 19 Unadjusted Prevalence and APHO Diabetes Prevalence Model YearQOF Indicator ( DM19 ) % PrevalenceAPHO Diabetes Prevalence Model for England (number) APHO Diabetes Prevalence Model for England (% Prevalence) 2005-620,456 2006-721,0323.7 2007-822,4373.9 2008-923,8354.233,1937.3 2009-1025,1714.433,9747.4 Dec 201026,017 202042,5068.7

23. Worcestershire Diabetes X-PERT Courses as of 22 March 2011 YearProviderNumber of Courses Number of Completions 2008-095 Practices979 2009-105 Practices1196 2010-117 Practices1090 2008-09DSNs14119 2009-10DSNs15129 2010-11DSNs31267 Total88790

24. The Scope of Diabetes Structured Education in Worcestershire SMEPatient GroupTotal Population2011-12 Diabetes X-PERT Core Diabetes Type 2 Adults 24,000 approx50-60 courses Update modules10 sessions Insulin initiation X-PERT insulin5-10 courses DAFNEDiabetes Type 1 Adults 2,000 approx6 courses Insulin pumps X-PERT Insulin Update modules Insulin initiationChildren with Diabetes 300-400 Insulin pumps Cascade or similar

25. X-PERT Insulin Module DSNs trained to run this module Suitable for people with Type 1 and Type 2 Initial emphasis on Type 2 Diabetes

26. Update Sessions Repeat of sections of the manual for the update and updates run in a variety of formats including: A fixed number of updates spread out through the year on set topics which patients could choose from Multiple options event

27. Patient Experience Collect Collate Evaluate Report

28. Currency for Diabetes Courses 2011-12 £3,200 DAFNE £1,500 X-PERT Insulin Module £1,000 X-PERT Core module £200 X-PERT Update Sessions

29. Personalised Care Planning and Diabetes X-PERT programme The new X-PERT core module patient handbooks make explicit reference to personalised care planning The new Diabetes X-PERT Insulin module makes explicit reference to personalised care planning We will be migrating to the new patient handbooks starting in April 2011. Do you understand what personalised care planning is? Can you explain it to patients?

30. IT Templates and Personalised Care Planning IT Templates for care planning which can: Record the essential components of a care planning consultation as part of the routine clinical record. Enable reports generated to include this critical patient related information Generate important, personally relevant patient information before and following the consultation. Provide aggregated data to support person/patient centred commissioning for those with LTCs

32. Patient Experience Comments “The first week I wanted to run away because I didn’t think that it was relevant to me but then I realised that only I can take ownership for my diabetes and seeing my results confirmed all this.” (Diabetes X-PERT Core Module Participant, Worcestershire) “I now feel very positive about testing and recording my results - I feel more in control” ( DAFNE course participant, Worcestershire)

33. Practices Running X-PERT 2011-12 Move to independence New funding request form Ordering patient handbooks

34. Moving Forward 2011-12 X-PERT Insulin module X-PERT update sessions Moving to the new Patient Handbooks Moving to the latest Educator Manual Diabetes X-PERT Educators Register Electronic Diabetes Health Profile as part of personalised care planning Personalised care planning and structured education start to become the default options by which diabetes patients interact with the health services in Worcestershire