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Care Planning

Definition
The Department of Health defines care planning as:
"a process which offers people active involvement in deciding, agreeing and owning how their diabetes will be managed.  It is underpinned by the principles of patient-centredness and partnership working…  It is an on-going process of two-way communication, negotiation and joint decision-making in which both the person with diabetes and the health care professionals make an equal contribution to the consultation.

Purpose
The Healthcare Commission survey (Healthcare Commission. (2007). Managing Diabetes: Improving Services for People with Diabetes. Service Review), showed that contact time in traditional consultations are often spent neither efficiently not effectively in terms of supporting self-care. Although 95% of people with diabetes, for example, are seen annually, only 50% discuss a plan to manage their diabetes and less than 50% discuss their own goals for self-management (Healthcare Commission, 2007. Managing Diabetes: Improving Services for People with Diabetes. Service Review). Half the current time devoted to routine diabetes care is thus wasted. The idea of year of care planning is to deliver something more effective & efficient via care planning.

Projected Benefits

Patients’ perspective

  • Involvement in decisions about their care

  • A better understanding of their condition

  • Respect for and recognition of their everyday work to self-manage

  • Tailored support to increase confidence and skills in self-management

  • Consistency and continuity of care – the person with diabetes is the most consistent provider

    of their own care

  • A central role in service planning, and agreeing what local care should look like

  • Information and signposting to local support services

Clinicians Perspective

  • More satisfying consultations

  • A lever with commissioners to agree more time with patients

  • Commissioning influenced by genuine clinical data

  • Services commissioned that people with diabetes will use

  • Better outcomes for people with LTCs

  • A new and interesting skill set

  • A lever to improve clinical IT and drive quality improvement

  • Less inappropriate use of medication

Process of Care Planning at the Wolverhampton Diabetes Centre
Please see below for an outline of how the care-planning process will work in practice. Click to enlarge image.

The person with diabetes will be given an opportunity to comment on their consultation and care-planning at the end of visit and complete a questionnaire about the consultation which will be used to provide rolling feedback to support and improve care. Click on the links below for the different documents that make up the care plan.

My Care, My Plan

Systematic Review

Letter Template

Patient Satisfaction Questionnaire

Personalised Care Planning Resources

For Health Care professionals
Year of Care concept
Getting to Grips with the Year of Care
Co-creating Health

For patients:
http://www.diabetesselfcare.org/self-care-behaviors/overview/
https://careplan.nhslocal.nhs.uk/about/faq
How to prepare for your consultation.docx