Care Planning What is it Claire Scott Care

Care Planning. . What is it? ? Claire Scott Care Planning Lead Berkshire West

Long term conditions are different Hours with healthcare professional = 4 hours in a year Self-management = 8756 hours in a year

The evidence base in all long term conditions Organised proactive system Engaged empowered patient = Better outcomes Partnership In England : The Diabetes NSF Internationally: The Chronic Care Model - Wagner

Care plans versus Care planning Having better Conversations

1 st visit Information gathering HCA performs annual review tests Between visits Information sharing Sent to patient > 1 week before consultation; with agenda setting prompts Consultation and joint decision making Prepared HCP and patient Agreed and shared goals and actions (care plan) Resultant care plan shared with patient, immediately or by post 2 nd visit

Diabetes care plan COPD care plan Arthritis care plan Depression care plan

Your care plan

NWRCCG Practice. Completed training/Action Plan. Templates installed/visit from Claire Scott. Sending Results in advance of consultation Read Codes embedded Balmore Park Sept/Nov 2013 √ √ √ Emmer Green Jan/Mar 2013 √√ √ ? Peppard Rd April/June X X X Priory Avenue April/June √√ √ √ Circuit Lane May/Jun 2013 √√ √ ? Western Elms Oct/Dec 2013 √√ √ √ Tilehurst Surgery Jan/Mar 2013 √√ √ √ Mortimer Jan/April 2014 √√ √ ? Theale Oct/Dec 2013 √√ √ ? Pangboune Oct/Dec 2013 √√ √ ? COPD/LTC care planning LTC training √ √ staffing √ await HCA training 05/05/2015 phone/email phone/email √ √ √ Sept FU Call/visit √ yes/phone/email yes

SRCCG Practice Training Completed & Templates Uploaded Action Plan (Claire Scott visit) Sending results in advance of consultation. Read Code Embedded LTC Care Planning training COPD/LTC care planning FU visit/ mentoring 08/04/2015 University Practice √ Millman Rd, Lister √ √√ ? √ Yes Milman Rd, Kumar √ √√ √ √ yes Tilehurst Village √ √√ √ x No Melrose, Dr Dean √ √√ ? x no Eldon Rd √ √√ √ √ yes London Rd √ √√ √ South Reading √ √√ √ √ Pembroke √ √√ √ √ Whitley Villa √ √ Kennet √ London St √ √√ Chatham St √ 79 Russell St Abbey Medical 41 Russell St Reading Walk-in centre √ No Sept Yes √ No √ √ DSN √√ √ √ no √ √√ √ √ √ √ √ √√ √ ? √ √√ √ √ √ 22/04/2015 yes yes Melrose, FAB Williams √ √√ ? ? Longbarn Lane √ √√ √ √ No Shinfield √ √ √ Sept Yes Westwood Rd √ √√ √ √ No Grovelands √ √√ √ 22/04/2015

WCCG Practice Template Training Sending results in Read Coding installed/visit Claire Completed/Action Plan. advance of consultation. embedded. Scott Brookside Jan/Mar 2013 √√ √ Burma Hills Oct/Dec 2013 √√ √ Finchampstead Jan/Mar 2013 √√ √ Loddon Vale April/June √√ √ New Wokingham Rd Jan/April 2013 Parkside Oct/Dec 2013 Swallowfield Attended LTC Care COPD/LTC Care Planning training Planning FU visit/mentoring Visit 29/4/15 X Helen PM called X 29/04/2015 √ √ √√ √ √ May/Jun 2013 √√ √ Wokingham Medical Centre + April/June √√ X Twyford Jan/March 2014 √√ √ Wargrave Sept/Nov 2013 X X Wilderness Rd X X X Woodley Health Centre May/Jun 2013 Woosehill K 81092 Jan 2 -14 √√ √ 08/04/2015 visit 29/4/15 22/04/2015 Call PM 29/04/15 Kate Mansi 26/5/15 10 am email Kath Miller X Call 29/4 Shar Tanner X No X visit, call 29/4, email visit 29/4/15 √ X √ √

N&DCCG Practice Templates Completed uploaded/Claire Scott training/Action Plan visit. Sending results advance of consultation. Read Codes Embedded. Burdwood Jan/Mar 2013 √√ √ √ Thatcham Jan/Mar 2013 √√ √ √ Chapel Row/Bucklebury Jan/Mar 2013 √√ √ √ Hungerford Jan/Mar 2013 √√ √ √ Downland Jan/April 2013 √√ √ Kintbury May/Jun 2013 √√ Northcroft May/Jun 2013 √√ Attended LTC Care Planning Training. √ √ √ FU Visit COPD/LTC Care Planning Mentoring Yes Yes √ √ Yes √ ? All inclusive √ √ √ St Mary's Jan/April 2014 √√ Eastfield Sept/Nov 2013 √√ √ √ Yes Falkland Sept/Nov 2013 √√ √ √ Yes Lambourn Sept/Nov 2013 √ √ √√ √ yes need further Yes

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