- 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
- Contacts
- Year of Care resources
- References
- Year of care forum
- Year of care document library
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Care planning - the metrics
If care planning is to be embedded in routine care and new habits maintained, it will be important to use metrics in everyday practice to enable everyone to see that care planning is being delivered in practice; this includes people with diabetes who will want to know the service they use is delivering best practice and be able to exert choice if necessary.
The Year of Care (YOC) Programme has developed The Year of Care Outcomes Framework (PDF 2MB) to support health communities identifying suitable metrics to measure process and outcomes. This includes examples of questionnaires and where they can be accessed.
Care planning has many component parts (summarised in the ‘Care Planning House’) all of which are important to achieve good outcomes. Some of these are not easily ‘countable’ or measurable routinely. Year of Care emphasises the importance of developing a ‘learning’ or ‘reflecting’ organisation in which routine data fields are set up to record what is important (as well as what is easy) to measure, and teams develop audit and evaluations ‘frameworks’ that suit their circumstances and address the particular issues they are reviewing.
Based on the two visit model, there are four aspects which would benefit from measurement:
- What percentage of people with diabetes are sent
their results / or a prompt sheet before the
visit?
- To what degree are people being supported or
coached to develop their own goals and action plans, rather than have these
prescribed?
- To what degree are these being recorded
systematically in the records?
- To what degree is a summary of the consultation
being made available to people after the consultation?
The Royal College of General Practitioners (RCGP) Report 'Care Planning – Improving the lives of people with long terms conditions’ (PDF 715KB) acts as a practitioner’s guide on how to implement care planning and references to the many useful tools and techniques available to answer the following questions
- How
will we know how we are doing and do it better?
- How can
we improve out care planning skills?
- How
successful is our practice at enabling people to self mange effectively?
- How can we monitor our attitudes and our processes?
