Dementia Care Planning Guidance

Ensure Care Plans are in place and shared for all patients diagnosed with dementia and they are being reviewed annually.

Rationale

Patients diagnosed with dementia require robust care plans (and advanced care plans) developed in primary care.

Who are cohort within this CFF element?

Patients diagnosed with dementia.

Practices are being asked to provide the following to assess impact:

Practices to identify patients diagnosed with dementia who have a care plan in place that has been shared and has been reviewed annually

1)Identify patients diagnosed with Dementia;

2)Patient to have personalised care planning in place that has been shared with partner organisations/carers

3)Patients with a personalised care plan have had the care plan reviewed within preceding 12 months

How do I record the information?

SystmOne – Ardens Users / SystmOne – Non Ardens Users / EMIS Web
Use the Dementia template to capture key information.
-Click on Care Plan
-Click on Generic Care Plan make sure you select the code from the drop down box
Signpost patients (where appropriate) to self-management support on the Health in Herts webpages / Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES.
Signpost patients (where appropriate) to self-management support on the Health in Herts webpages / Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES.
Signpost patients (where appropriate) to self-management support on the Health in Herts webpages.

Reporting Requirements/Frequency

Practices to complete Dementia Register and submit data on a quarterly basis:

1)number of patients on register

2)number of patients on register with a care plan

3)number of patients who have had a review within the preceding 12 months

CCG to review submissions quarterly and report to the Dementia Strategy Group.

Agreed payment for care planning

This payment is for those patients who are not moderately or severely frail and who therefore would be unlikely to otherwise meet the criteria for payment for care plans. Dementia plans will be reimbursed at a rate of £50 and SMI checks will be reimbursed at a rate of £30.

Sharing the care plan

Once you have identified your cohort and completed the care plans, you need to ask for consent from the patient to share information.

With the patient:

  • Print or email the documents to the patient

With other professionals

  • With the permission of the patient, practices can add additional information about specific conditions to the summary care record to make it an enhanced summary care record.
  • Once you have selected this read code and saved the record, there is nothing further for you to do as the system will automatically upload the information.
  • Patients at S1 practices can consent to having their whole record shared with other S1 users e.g. hospices and this will give a more in depth picture to other health care professionals.
  • More information can be found here:
  • The sharing of patient records and care plans/treatment plans is part of the wider “My Care Record” project

Read Codes

SystmOne (CTV3 Code) / EMIS & Vision (v2 Code) / SNOMED Concept ID Code (SNOMED replaces Read CTV3 & v2 in all GP systems during 2018)
Dementia care plan / XaaBZ / 8CMZ / 869791000000101
Dementia care plan agreed / XacIx / 8CMZ0 / 956841000000106
Dementia care plan declined / XacIz / 8CMZ2 / 956881000000103
Dementia care plan reviewed / XacIy / 8CMZ1 / 956861000000107
Dementia care plan review declined / XacJ0 / 8CMZ3 / 956901000000100
Dementia advance care plan / XacLx / 8CMe0 / 959361000000105
Dementia advance care plan agreed / XabEk / 8CSA / 713600001
Dementia advance care plan declined / XabEi / 8IAe0 / 956881000000103
Dementia advance care plan review declined / XacM2 / 8IAe2 / 959461000000102
Review of dementia advance care plan / XabEl / 8CMG2 / 956861000000107

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