Getting Started with Care Planning
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
how
We have a process to offer and arrange both appointments
We have decided how long the consultations will be
We have room to accommodate these appointments / Example Poster–‘ You and your Diabetes’ ExampleLeaflet: ‘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” leaflet
Sample 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 patients
We 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 consultation
We 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 pack
b) ‘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 go
How are we doing overall?