1. PERSONAL HEALTH PLANS Dr Alison Jackson
GP & CCG Long Term Conditions Lead

2. PERSONAL HEALTH PLANS
Personalised care and support planning encourages care professionals and people with LTCs to work together to clarify and understand what is important to that individual. They agree goals, identify support needs, develop and implement action plans, and monitor progress. This is a planned and continuous process, not a one- off event. Coalition for Collaborative Care 2014

3. VISION
To develop an integrated care plan, used by all providers called ‘My Health Plan’, to ensure that people are involved in managing their condition, receive the care they need to live and die well, and that both they and their carers feel better supported to maintain a good quality of life.

4. COLLABORATIVE CARE AND SUPPORT PLANNING: AN INTRODUCTION

5. Why?
Patients with multiple LTCs are on the rise and we need a more holistic approach to meet their needs
Patients with multi-morbidity end up with many care plans that do not work for them or their clinicians
Variation in delivery of care plans across the CCG
Not person-centred-more disease specific
Evidence suggests it leads to more appropriate use of resources ,people more engaged and can self-manage more effectively and adopt a more healthy lifestyle.
Need better integrated approach with whole system buy-in so all health and social care professionals are involved.

6. BENFITS TO PEOPLE WITH LTCs
Involvement in the decision making process
Better understanding of their condition
Develop ability/increase in confidence to self manage
Provide consistency and continuity of care
Information and sign posting to local services
Opportunity to have a central role in service planning, and agreeing what local care should look like
Involving carers more in regards to identifying and supporting their health and care needs

7. BENEFITS TO CLINICIANS
More satisfying consultations
See better outcomes for people with LTCs
New skill set if it is to be truly integrated.
A lever to drive quality
Less inappropriate use of medications
To test services commissioned that people with LTCs will use.

8. BENEFITS TO COMMISSIONERS
Greater value for money by improving health outcomes and reduce waste
Positive impact on patient experience such as prevent unplanned care.
Provides information needed to commission services that people want and clinicians value
Fits very well with integration agenda and will add value to HomeFirst Plus
Provides sustainable, long term approach to reducing the burden of LTCs on local resources