The Care Planning Practice Checklist

Getting started with Care Planning

This Care Planning Practice Checklist has been developed to support practices new to Care Planning.

It is available to accompany the Practice Pack: a handbook to help Practices get started with Care Planning. It can be obtained from your local Year of Care Team.

The checklist is based on the experiences of other teams. It can be used by a practice team to identify what is needed at each of the key steps in the care planning process.

This resource will allow you to map how your team is doing and identify “next steps’ as it guides you through the Care Planning process as a checklist.

It will help you to cross-check what it’s important to have in place and signpost you to some resources that are available.

Care Planning is not something a doctor or nurse can do in isolation: they need the systems and support of their Practice and Commissioners to make the process work.

The Care Planning Practice Checklist

What have you got? Which one applies best?Anchor

points –these are roughly

chronological

We have cracked

it

We are nearly

there with this

We have good ideas, but needs more work

What are the next steps

for us?Where can we get more

help with this?

Organisation that supports preparing patients and staff

We have a robust register and recall system in place for our patients with a long term condition(s)We have decided which staff will be involved at each step- data collection appointment- care planning appointment- who will do the admin’ and howWe have a process to offer and arrange both appointmentsWe have decided how long the consultations will be

We have room to accommodate these appointments

Example Poster –‘ You and your Diabetes’ Example Leaflet: ‘Care and Support Planning “

We have decided how we are going to market care planning to patients: to prepare patients for the change to their annual review appointment

Information /structured education e.g. DESMOND or Xpert / DAFNE / Pulmonary Rehab

What have you got? Which one applies best?Anchor

points –these are roughly

chronological

We have cracked

it

We are nearly

there with this

We have good ideas, but needs more work

What are the next steps

for us?Where can we get more

help with this?

Information gathering appointment

Our reception staff are clear about the new appointment system and understand the order in which things happen

We have an information leaflet explaining the changes to annual review appointments

Example leaflet: ‘Care and Support planning” leafletSample invitation letters

We have an agreed list of tests and a member of staff who is competent to perform them

‘Contact numbers and safety netting’: Tests that would be performed and parameters for which the tester would seek advice

We have a method of data entry into a long term conditions template (in our medical records) and a decision about who will enter this data

IT guidance: ‘Installing and configuring the YoC Information gathering template’

What have you got? Which one applies best?Anchor

points –these are roughly

chronological

We have

cracked it

We are nearly

there with this

We have good ideas, but needs more work

What are the next steps for

us?Where can we get more help

with this?

Information sharing between appointments

We have a system for sending results to patients, 1-2 weeks before Care Planning appointment

IT guidance: can be adapted for local use.See box below

We have an agenda setting sheet for long term conditions to share results with patients and allow them to think about their results before the care planning consultation.The letter needs to have a recent result and one or two previous results if possible

IT guidance: ‘Installing the diabetes results and care plan’. ‘Creating, editing, printing and saving a merged diabetes results and care plan.’ ‘Example– Diabetes colour leaflet, ‘COPD results and care plan,’ ‘Cardio-vascular disease results and care plan, ‘Health Checks results and care plan, ‘What could really make a difference’Resources for patients with multimorbidity and frailty.

We have an accompanying explanatory document so that people can interpret their results

Example- leaflet ‘Your diabetes results’ Explanation of results. ‘Key Conversations’ leaflet

We know who will print the results letter/ or agenda-setting sheet and send it to patientsWe have a system for people to either make an appointment or alter a pre-arranged appointment for their care planning consultation

What have you got? Which one applies best?Anchor

points –these are roughly

chronological

We have cracked it

We are nearly

there with this

We have good ideas, but

needs more work

What are the next steps for

us?Where can we get more

help with this?

Consultation and joint decision-making with a “prepared HCP” To produce an agreed and shared care plan

We have a system that facilitates the recording of an agreed and shared care plan

We have a template for the agreed care plan (to summarise consultation) that includes these 3 elements:

A system to record the care plan

IT guidance:‘Adding relevant diabetes YoC read codes to existing practice templates’ ‘Installing the diabetes results and care plan.’ ‘Creating, editing, printing and saving a merged diabetes results and care plan.’Example of a completed care plan / multi morbidity and frailty – ‘My plan’

A method of providing the patient with a copy A system to collate the goals and actions

We have an integrated multidisciplinary team with long term conditions expertise and the skills they need to work in partnership and provide self-management support

What have you got? Which one applies best?Anchor points –these are roughly chronological

We have cracked it

We are nearly

there with this

We have good ideas, but

needs more work

What are the next steps for

us?Where can we get more

help with this?We have a protected appointment that allows time for a meaningful consultationWe have accessible results prior to consultation

We have a menu: of local resources and support available in our area.For each individual clinician*I am comfortable with my ‘gather & share stories’ skills

Consultation skills/ attitudes a) ‘Self-reflection tool for care planning’ in practice packb) ‘Mind your language’ resource (may be on disc in future).c) ‘Health care professional / person with LTC feedback forms’

I am comfortable with my ‘explore & discuss’ skills

I am comfortable with my ‘goal setting and action planning’ skills

We’ve had a bit of a goHow are we doing overall?