Care planning: why, how and the importance of standardisation

Suzanne Lucas & Anne Goodchild

Survey: have you ever attended any training for care planning

Yes No Learnt about it from others

Not sure

Qualified cliniciansHCA’sNon clinicians

Survey: is care planning part of your routine practice?

Yes Partially NoQualified cliniciansHCAs

Question directed: clinicians & HCAs who have experienced care planning training or learnt about it from others

Survey: If no, what were the barriersBarriers

Survey: is care planning part of your routine practice?

Yes Partially NoQualified cliniciansHCAs

Question directed: clinicians & HCAs who have not experienced care planning training or learnt about it from others

Survey: If yes, can you describe what you are doing?Examples

Survey: are you aware if care planning is used in your practice?

Yes No Not surePractice managersOther non clincinans

Question directed: Practice Managers and other non clinicians

Care planning: why?

Meets UK national standards, policy and guidelines:

• 2014 NHS England Action for Diabetes• 2011 NICE Quality Standard 3 ‘people with diabetes participate in annual care planning

which leads to documented goals and an action plan’• 2010 DH White Paper there was a commitment to ‘shared decision making’ and ‘choice’ as

part of the care planning process• 2001 National Service Framework for Diabetes Standard 3 encourages participation in the

decision-making process• 2008 Darzi High Quality Care for All advocates use of jointly agreed personalised care plans• 2006 Department of Health and Diabetes UK provides theoretical basis for care planning

Translates into real self care behaviour change Professionals report greater job satisfaction and improved skills and time efficiencies

Care planning: how?

Engaged,

informed patient

HC

P com

mitted to

partnership working

Organisational processes

Commissioning- The foundation

Collaborativecare

planning consultation

“Agreed & shared care plan”

Information gathering Health Care Assistant or Practice Nurse performs

screening tests

Sent to patient >1 week before consultation; with agenda setting prompts

Prepared nurse / doctor and patient

Resultant care plan shared with patient, immediately or

by post

Information sharing

Consultation & joint decision making

Year of Care

How Co-Creating Health works

The clinician’s and the patient’s priorities:

Voicing both, acknowledging both and then working out whatthe patient wants to work on, not work on or come back and discuss.

HbA1c 68mmol/mol, not

picking up prescriptions, not

checking blood glucose & on a sulphonylurea

Girlfriend has just left, struggling with shift

work, forgetting medication, eating

“rubbish”, feeling lousy

DMI: three minimum standards

Care planning is a way of making sure time spent between patients and healthcare professionals is used in the best possible way, so that when they come together they can;

1. set goals 2. have a record of these3. follow up and talk about progress

www.dmi-diabetes.org.uk

The personal health record

Documenting care planningCARE PLANNING TEMPLATE Codes

Goal identification 67L

Identifying barriers to goal achievement 67R

Goal achieved drop down Goal not achieved

67L0 (zero)67L1

• Follow up arranged drop down Follow up in 1 month Follow up in 2-4 months Follow up in 4-6 months Follow up in 1 year

8H88H878H888H898H8B

Personalised care plan completed 8CMD

What do you think?

Please complete the voting paper on your chair

• What model for Camden?• What resources would suit you?• Your comments