S78 - Day 1 - 1430 - Care support and planning in practice

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  • The Care and Support Planning conversation can now take placeThe individual has had the chance to think and prepare The care professional has had the chance to review clinical records and assessmentsThere is now more time to spend having a good quality discussion For the Individual this meansYou are listened to and understood – your perspective is importantYou will feel like you are working together with your care professional You get the chance to ask questions , discuss options and come away with a clear plan based on what is important to you including identifying what you can do for yourself and what care and support you might need from other peopleFor the care professional this meanslistening and valuing the individuals perspective/ideas and goals Not taking everything at face value – digging a little and exploring ideas Holding back from going into fix it modeSupporting the individual to set their own goals and plans Learning and using some new consultation skillsWorking in a way you have always felt was better
  • So why care and support planning?1) In discussions with our members - health and social care charities - it became clear that care and support planning improved outcomes for a wide range of people with care and health needs over time. But despite no shortage of policy level commitments, statistics showed that it was not happening anywhere near enough.2) At the same time, National Voices began working with the Year of Care Partnershipsteam to discuss the House of Care model. As Sue has mentioned earlier in the presentation, the left wall of the House is about making sure that people and their carers are informed about, and can engage with, care and support planning. 3) Around the same time, colleagues at the CSA and I were looking at the emerging shape of the Care Bill. This was also set to place a requirement on local authorities to create a care and support plan where it was required or chose to meet needs. 4) Integration has been a key driver in the health and care world. Many of you will know the Narrative for person centred Coordinated Care which sets out what coordinated care would feel like from the perspective of a person receiving it. Parallel drivers for developments care and support planning in health and social care – an opportunity to develop a more coordinated approach that keeps the person at the centre, building on the best learning from both health and social care. But how were going to take this forward?
  • So we continued to work with a range of partners to develop a draft guide and soft launched this at the Future of Health Conference in October 2013. As you can see here, the principles and 4 stages are still upfront but the buttons along the side show how we had started to develop additional information including: The role of the lead professional as we called it at that point, now the care and support partner – the professional or support with whom the person would have their care and support planning discussion. I’ll come back to this shortly. How the approach can benefit people and professionalsSome common Q&As Case studies Before the soft launch of the guide, I became aware that I’d been having all these interesting discussions with all these separate partners but it would be even more valuable is we could bring together everyone who is interested in making this happen so that they could discuss where we’ve got to and where we want to take this piece of work.


  • 1. 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
  • 2. 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
  • 3. Hours with health / social care professional = 4 hours in a year Self-management = 8756 hours in a year The individual’s perspective
  • 4. The Challenge! 15 Million people live with long term conditions in England Care and support planning can make it personal for everyone!
  • 5. International Evidence Base Reproducible intervention >3000 practitioners and 40 quality assured trainers Year of Care Training and Support Team
  • 6. Care and support plans versus Care and support planning Having better Conversations Year of Care
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. 4. Review Checking how things are going by • Self monitoring • Support programme / friends • Review with the care and support partner that helped create plan
  • 13. 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
  • 14. Purpose of today’s event More than Medicine
  • 15. 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
  • 16. Impact ……I'm listened to …….you may not have all the answers …….you’ve helped me work things out Year of Care
  • 17. 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
  • 18. 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
  • 19. “ ‘I enjoy doing the clinic a lot more now… working with them rather than at them’ Better for Staff too Year of Care
  • 20. ‘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
  • 21. 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%)
  • 22. 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
  • 23. Launching today
  • 24. Supporting local communities to build their House of Care Find out more: www.coalitionforcollaborativecare.org.uk Twitter : https://twitter.com/Co4CC
  • 25. What is care and support planning? An introduction to our guide
  • 26. 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
  • 27. 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.
  • 28. 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
  • 29. The ‘how’
  • 30. The ‘how’ • c200 individuals signed up. • Health and social care professionals, commissioners, providers, academics, people who use services, carers
  • 31. The ‘what’
  • 32. The ‘what’
  • 33. The ‘what’
  • 34. The ‘what’
  • 35. The ‘what’
  • 36. The ‘what’
  • 37. The ‘what’
  • 38. The ‘what’
  • 39. 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
  • 40. Contact Lindsay Oliver Sue Roberts Enquiries@yearofcare.co.uk www.yearofcare.co.uk Laura Robinson, National Voices Laura.robinson@nationalvoices.org.uk