- The Year of Care Pilot Programme
- The policy context
- Why Year of Care? The case for change
- What works for LTCs
- Care planning - what is it?
- The benefits
- The care planning training support programme
- Information technology
- Commissioning and Year of Care
- About us - Year of Care Partnerships
- How to get going with care planning
- Year of Care resources
- Year of care document library
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Care planning - what is it?
Care planning is an approach, to putting self management support into practice, in a systematic way, as part of routine care for people with long term conditions (LTCs). In diabetes it replaces the annual surveillance review, which is sometimes a tick box activity to fulfil QOF requirements, with a collaborative consultation. Care planning is suitable for people with other single or multiple LTCs who currently do not receive systematic care processes.
What is care planning?
The Department of Health defines care planning as:
"a process which offers people active involvement in deciding, agreeing and owning how their diabetes will be managed. It is underpinned by the principles of patient-centredness and partnership working It is an ongoing process of two-way communication, negotiation and joint decision-making in which both the person with diabetes and the health care professionals make an equal contribution to the consultation.
The underpinning philosophy of care planning in the Year of Care (YOC) approach states:
- people with LTCs are in charge of their own lives and self management of their condition/s, and are the primary decision makers about the actions they take in relation to their diabetes management
- people are much more likely to undertake action in relation to the decision they make themselves than decisions that are made for them
These statements emphasise the importance of the philosophy and the process in achieving outcomes rather than the written care plan that may emerge at the end of the process, encapsulated in the strap YOC line its a verb and not a noun.
Despite the simplicity of the message, care planning is a complex intervention involving changes in attitudes, skills and service infrastructure.
The 'Mind your language' toolkit (PDF 156KB) is a resource to support teams to meet the challenge of ensuring care planning is delivered in a style and according to a philosophy that supports self-management. The core elements of care planning are described inGetting to Grips with YOC (PDF 2.5MB), and the philosophy, rationale and practice of a care planning consultation are detailed in Partners in Care A Guide to Implementing a Care Planning Approach to Diabetes Care (PDF 3.7MB) . The evidence base for the components to deliver care planning is found in Graffy J, Eaton S, Sturt J & Chadick P. (2009). Personalised Care Planning for Diabetes: Policy Lessons from Systematic Reviews of Consultation and Self-Management Interventions. Primary Health Care Research & Development, 10, 210-222.