The process in primary care
Personalised care and support planning seeks to rearrange the way routine care is delivered to create an opportunity for more productive and useful conversations between people with long-term conditions (LTCs) and their healthcare professional.
Year of Care has worked with a number of charities, national organisations and grassroots practitioners to develop and test a person-centred approach to long-term condition reviews in primary care.
This diagram shows how this is carried out in general practice using a two ‘contact’ Year of Care approach.
This two stage process is demonstrated in practice with a person with multiple long-term conditions in the video below.
The aim of the process is to separate out the collection of tests and assessments from the personalised care and support planning conversation which creates an opportunity for a more forward looking discussion informed by preparation and the sharing of routine results. The approach includes:
- A single information gathering appointment which ensures all disease surveillance associated with any condition a person lives with is completed at a single information gathering appointment with a healthcare assistant
- Triage and identification of clinical issues (professional preparation) which is particularly important for those living with multiple conditions and complexity to identify medication and clinical ‘red flags’, and triage to an appropriate professional
- Patient preparation: sharing information with people ahead of their personalised care and support planning conversation (agenda setting prompts and routine results) so that individuals are enabled to understand and participate more fully in decision making and planning around their self-care
- A personalised care and support planning ‘conversation’ using a person-centred, solution focused approach including the development of a personalised care plan, often linking people to either traditional or ‘more than medicine’ approaches
Personalised care and support planning differs from traditional treatment planning in that it seeks to offer a partnership approach and to help the person identify their priorities, personal goals and action plans and services available to support these. It acknowledges the role of the individual in carrying out all the day to day activities that contribute to long-term condition management.