Documents

Some of the documents listed below are also listed in the self care resource pack. They are listed here because they have relevance to care planning as part of self care.

1. Supporting people with long term conditions: commissioning personalised care planning - a guide for commissioners

This guide for commissioners is part of the Putting People First, Transforming Adult Social Care policy. It provides commissioners of health and social care services with the information and support they need to fulfil their obligation to embed personalised care planning in their localities. It describes what person centred and integrated care planning is, what the benefits are and what this means for them as commissioners. Care planning is an essential element of supported self care.

2. Impact assessment for implementing personalised care planning for people with long term conditions

This document lists the evidence base, specific targets, risks and cost benefits of implementing care planning and is essential reading for commissioners.

3. Generic choice model for long term conditions

This document offers a best practice generic model with associated case studies, for commissioning services for those with long-term conditions to support choice and personalisation of care.

4. Common core principles to support self care: a guide to support implementation

The principles were developed by key stakeholders including people with long term conditions. They recognise that people are best placed to understand their own needs and how to meet them and are intended to support self care in its broadest sense.

5. Outline service specification: personalised care planning for people with long term conditions.

This has been developed to help commissioners to put in place appropriate arrangements to ensure people with long term conditions have informed choice of, and access to, services that best enable them to manage their condition. The aim is for personalised care planning and patient information to come together as a seamless, facilitative and holistic process of care delivery that promotes empowerment and choice.

6. Pharmacy in England: Building on strengths – delivering the future

This White Paper sets out the Government’s vision of the future role pharmacists can play in delivering world-class pharmaceutical services. This includes pharmacists acting as centres within the community promoting and supporting healthy living and healthy lifestyle, providing advice and support on self care, and offering new services to those with minor ailments and long term conditions such as routine monitoring, vascular risk assessment and support for making best use of their medicines.

7. Working together for change: using person-centred information for commissioning

This describes a simple six-stage process that uses person centred information (for example from person centred reviews, person centred plans or support plans) to drive strategic change and commissioning.

Briefly the six stages are:

  1. Gathering information
  2. Capturing what is working and not working
  3. Clustering this into themes
  4. Analysing the themes
  5. Action planning conducted on the basis of the thematic analysis
  6. Sharing information to inform local strategy and commissioning

8. Partnering in self-management support: A toolkit for clinicians

Enabling people to make good choices and sustain healthy behaviours requires a collaborative relationship between health care providers and patients and their families, the purpose being to inspire patients to become informed about their conditions and take an active role in their treatment. This document describes the skills and tools to transform the patient/health care professional relationship into a collaborative partnership. Care planning is at the centre of the cycle of care described here. This work originated in the USA but has heavily influenced practice in this country.

9. Your health, your way: information for healthcare professionals

This information booklet has been produced for healthcare professionals who are beginning to integrate the philosophies and goals of ‘Your health, your way’ into clinical practice. Personalised care planning and the subsequent care plans are two of the five core elements of ‘Your health, your way’.

10. Good care planning for people with long term conditions

Following the publication of the NSF for people with Long term Conditions, the NHS Modernisation Agency commissioned by Matrix to identify and report on the key elements of good care planning. This document gives user-friendly guidance and tools to assist local service providers to implement evidence based, person centred care planning.

11. Partners in care: a guide to implementing a care planning approach to diabetes care

The Year of Care model, developed by the National Diabetes Support Team, helps people to exercise choice and be partners in decisions about their own care, and supports them to self care effectively. It makes routine consultations between clinicians and people with long term conditions truly collaborative, through care planning, and ensures that the local services people need and want to support this are identified and made available, through commissioning.

The first year of this three-year project used the pilots as a ‘test bed’ for these ideas. They have produced a detailed commissioning model for care planning diabetes, which is generic for all long term conditions, and two practical guides to the programme and to care planning.

12. Getting to grips with the year of care: a practical guide

This guide is designed to help commissioners, clinicians and networks interested in setting up the Year of Care model locally. It concentrates on what needs to be put in place and the key role of commissioning.

  • Download the report (PDF) Diabetes UK, NHS National Diabetes Support Team, Department of Health, Health Foundation, 2008.

13. NHS Cornwall and Isles of Scilly Personalised Care Planning template

Personalised Care Planning: Commissioning requirements for provider organisations.

14. NHS East of England My Health Plan template

This health plan is designed to help people record information, which is important and useful to them in managing your long term condition(s). The plan can be completed in stages, over a period of time.

15. Personalised Care Plans presentation template

This generic set of slides about Personalised Care Plans is designed so that you can add your own logo and information.

16. How to deliver high-quality, patient-centred, cost-effective care

Consensus solutions from the voluntary sector. Based on evidence collected by ten leading voluntary sector organisations, this report identifies five key themes that health and social care need to address in order to ensure quality and sustainability.

17. E-LfH

Personalised Care Planning course developed by NHS Employers on behalf of DH and delivered by DH e-Learning for Healthcare is suitable for all health and social care professional involved in managing long term conditions. The course has three modules including an introduction to personalised care planning, how personalised care planning works and skills and behaviours for effective personalised care planning.

18. Advanced care planning: A Guide for Health and Social Care Staff

Advanced care planning is an extension of the care planning and review process but it takes place in the context of anticipated deterioration in an individual’s condition.

19. Message in a bottle

This is a simple but very effective emergency information scheme. Patient’s details are stored in a clearly labelled plastic bottle, which is kept in the patient’s fridge. A special label, which is recognised by the emergency services, is displayed near the front door.

20. No more blind dates

This project in Kirklees was to develop and implement an individual emergency care plan for patients. This care plan is agreed with patients, identifies early warning signs of deterioration in their condition, and sets out appropriate actions.

This means that there is effective communication between the ambulance service, the community matron team and secondary care. Ambulance staff have essential information, allowing them to manage patients appropriately and possibly avoiding hospital admissions. Early evaluation shows that the scheme has resulted in fewer 999 calls, fewer hospital admissions, improved liaison between health professionals and improved understanding and better management of the condition by patients and carers.

Further information from Angela Harris, Community Matron, Kirklees Community Healthcare Services, email Angela.harris@kirkleeschs.nhs.uk

21. Patient leaflet on personalised care planning

Explanatory leaflet for patients.

22. Contracting for Personalised Outcomes

23. Lifepsychol Quality of life tool

Drawing on the experience and learning of six local authorities, this document provides a summary of the main components of the contractual models and provides some key messages from case studies.

24. APPG on LTC

This All Party Parliamentary Group for Long Term Conditions will soon be set up with the increasing support of MPs and Peers from all political parties.

25. Information sheets from Department of Health

Three ‘at a glance’ information sheets have been published by the Department of Health:

  • Personalised care planning
  • Personalised care planning diagram
  • Care Coordination.

A leaflet explaining care planning for patients is also available.

26. Care planning WebEx

Dr Shahid Ali recently presented a WebEx on how his practice re-designed their LTC care to offer personalised care planning to patients, which has demonstrated significant impact both in use of acute care as well as primary care workload. The WebEx also discusses Dr Hannan Amir's practice approach to empowering patients to self-care, which forms the 1st half of the WebEx recording.

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