s78 - day 1 - 1430 - care support and planning in practice
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TRANSCRIPT
Care and Support Planning in practice
Lindsay Oliver: National Director for the Year of Care partnerships
Laura Robinson : Policy and Communications Advisor ; National Voices
Sue Roberts : Coalition for Collaborative care / Chair Year of Care
Expo: Session S78: March 3rd 2014
Have confidence in doctors and nurses?
Feel listened to/involved?
Take their tablets as prescribed
Outcomes as good as could be?
Get regular checkups?
People with long term conditions….
Would like to do more for themselves ?
Have confidence to manage day by day?
Year of Care
Hours with health / social care professional = 4 hours
in a year
Self-management = 8756 hours in a
year
The individual’s perspective
The Challenge!
15 Million people live with long term conditions in
England
Care and support planning can make it personal for everyone!
International Evidence Base
Reproducible intervention
>3000 practitioners and 40 quality assured trainers
Year of Care Training and Support Team
Care and support plans versus
Care and support planning
Having better Conversations
Year of Care
Care and Support Planning :
in the beginning
Agreed & shared ‘care plan’
Information gathering
Professional Story
Information Sharing
Person’s Story
Goal Setting and Action Planning
Year of Care
I got more information out of it than I ….did previously. …they were
probably giving us the information,(but) they were giving
it us in a different way. [PWD12]
Care and support planning
– being systematic
1st visit/
contact
Between contacts
2nd visit/ contact
… Absolutely 100% better ……for me and for the patients.[GP}
Information Sharing
and Reflection
Agreed and shared goals and actions (care plan)
Consultation and joint
decision making
Information gathering
Year of Care
1. Prepare
Getting ready for the care and support planning discussion
• clear about purpose
• collecting useful and important information
• taking time to think and talk with other people
• what matters most to you
• what do you want to get out of the consultation
2. Discuss
Year of Care Review
Action
planning
Goal setting
Explore and
discuss
Gather and
share stories
Care Planning
Consultation
Information Sharing
and Reflection
Agreed and shared goals and actions (care plan)
Consultation and joint
decision making
Information gathering
3. Document
Writing down the main
points from the
discussion
• the main points that you have
talked about
• the plan belongs to the person
• easy to understand and use
• also part of the main health and
care record
4. Review
Checking how things
are going by
• Self monitoring
• Support programme /
friends
• Review with the care
and support partner
that helped create plan
The House of Care
Preparation for discussion Information Structured education Emotional & psychological support
Care and Support Planning
Attitudes and Skills Integrated Team working Champions and role models
Admin for prompts, tests, assessments
IT support for care and support planning
Identifying population
Key contact and navigation
Purpose of today’s event
More than Medicine
Building the House
• Part of local strategy for
LTCs
• Steering Group with
senior buy in
• Quality assured training
which links attitudes,
skills and infrastructure
• Hands on support for
practical change
Impact
……I'm listened to …….you may not have all the
answers …….you’ve helped me work things
out
Year of Care
Healthier living
‘I no longer smoke (Gave up 12 months ago) . I take the symptoms more seriously - try to nip chest infection in the bud’
‘I achieve a lot – I have become very conscious of what I eat and do more exercise. I started going
to the gym to lose weight’
Year of Care
Sustained improvement
‘Each time I get a greater understanding of my condition and understand more about how I can go about maintaining and improving it’. (P8)
Year of Care
“
‘I enjoy doing the clinic a lot more now… working with them rather than at them’
Better for Staff too
Year of Care
‘The new pathway ….. more efficient in time for both patients and health care professionals.’ (Practice
team member)
Practice organisation and
resources
Cost neutral at practice level
Pre Year of Care : £21 Post Year of Care : £21
Year of Care
Clinical care…….. Improving too!
Tower Hamlets
2006: Worst 10% in England
2012: 72% received all 9 processes in National Diabetes Audit: Best in England
Patient perceived ‘involvement in care’ rose from 52-82% Diabetes ‘control’: 24 - 35 % (national average = 19%)
Integration / coordination
•At the personal level
• Between health and social
care
•Between primary and
specialist health care
Tower Hamlets: 2012
Specialists attend 90% of quarterly primary
care cluster multidisciplinary
meetings
Year of Care
Launching today
Supporting local communities to
build their House of Care
Find out more: www.coalitionforcollaborativecare.org.uk Twitter : https://twitter.com/Co4CC
What is care and support planning?
An introduction to our guide
The ‘why’
1. Member feedback: improves outcomes but
despite commitments, is not happening
enough
2. House of Care: engaged, empowered
individuals
3. Care Bill: care and support planning in
legislation
4. Integration: care coordinated around the
individual, integrated personal budgets
Our aim
→ Create a common understanding of what care
and support planning means across health and
social care
→ Raise awareness of the approach amongst
those who could benefit.
The ‘how’
• What is care and
support planning and
why do we need it?
• Overarching principle
• 4 stages
• Identified that it would
be useful to have more
information for people
who use services and
professionals
The ‘how’
The ‘how’
• c200 individuals
signed up.
• Health and social
care professionals,
commissioners,
providers,
academics, people
who use services,
carers
The ‘what’
The ‘what’
The ‘what’
The ‘what’
The ‘what’
The ‘what’
The ‘what’
The ‘what’
Get involved
• Tweet about the guide #careandsuppportplanning
• Share the guide and the films with your networks
• Endorse the guide
• Share you stories
• Help us develop additional content
• Share your views on professional summary
Contact
Lindsay Oliver
Sue Roberts
www.yearofcare.co.uk
Laura Robinson, National Voices
