Public Health and Health Promotion
Long Term Conditions
Staff : The Benefits
Personalised care planning can lead to a range of benefits for individuals, commissioners, providers of services and the health and social care workforce. These centre on:
- embedding the personalisation of care and services ‘adding life to years’;
- promoting health through information and self care, people staying healthier for longer and therefore ‘adding years to life’;
- promoting independence and achievement of other goals such as returning to work or living independently;
- reducing health inequalities by standardising care across the country;
- promoting integration and partnership working;
- stimulating genuine choices, and those choices feeding into commissioning decisions;
- promoting a more planned, proactive approach to health and social care services;
- efficiency savings, e.g. reductions in hospital admissions, outpatient appointments and GP consultations; and
- improved user and staff satisfaction, including fewer complaints.
The personalised care planning process:
· puts the individual, their needs and choices that will support them to achieve optimal health and well-being at the centre of the process;
· focuses on goal setting and outcomes that people want to achieve, including carers;
· is planned, anticipatory and proactive with contingency (or emergency) planning to manage crisis episodes better (for those with complex needs);
· promotes choice and control by putting the person at the centre of the process and facilitating better management of risk;
· ensures that people, especially those with more complex needs or those approaching the end of life, receive co-ordinated care packages, reducing fragmentation between services;
· provides information that is relevant, timely and accredited to support people with decision making and choices (e.g. supported by an Information Prescription);
· provides support for self care so that people can self care/self manage their condition(s) and prevent deterioration (e.g. supported by Your Health, Your Way);
· facilitates joined-up working between different professions and agencies, especially between health and social care; and
· results in an overarching, single care plan that is owned by the person but can be accessed by those providing direct care/services or other relevant people as agreed by the individual, e.g. their carer(s). This may be a written or electronic document or may be something that is recorded in the person’s notes. The important aspect of this is that the care planning discussion has taken place with an emphasis on goal setting, equal partnership, negotiation, and shared decision making.
Statement of values and principles of personalised care planning
· Personalised care planning is a continuous process; however it will result in an overarching care plan that is regularly reviewed.
· It is a dynamic process of discussion, negotiation, decision making and review that takes place between the individual and the professional – who have an equal partnership.
· The process should be led by the individual with them at the centre, and be based upon their strengths, goals, aspirations and lifestyle wishes.
· Assessment and care planning views the person ‘as a whole’, supporting them in all their needs and individual diverse roles, including family, parenting, relationships, housing, employment, leisure and education.
· The person should be encouraged to have an active role in their care, be provided with information or signposting to enable informed choices, and supported to make their own decisions within a guidance of managed risk.
Care planning is an essential element of supporting a person to self care effectively.
Care planning for the LTC population
Potential benefits for people with long term conditions
| Potential benefit | Achieved through care planning by… |
|---|---|
|
Focusing on outcomes and goal setting such as walking unaided, living at home, returning to work |
|
Having a discussion with the person about their
full needs. This recognises that many things can impact on health
and well-being, such as addressing psychological or emotional needs,
social care needs or housing problems |
|
Providing people with timely and relevant information in a way that they understand, and support self care and self management |
|
Having someone to lead on the care planning process
and co-ordinate services can have a hugely positive impact for the
person and their carer, particularly for people with a range of
complex health and social care needs |
Reductions in:
|
Having contingency planning, e.g. who to contact,
what to do in a crisis episode. Increased self care and self management – there is evidence of reductions in GP and outpatients appointments. Supporting people to be independent, better management of risk, and perhaps use of assistive technology to support people to live at home if that is one of their goals |
| Better long term outcomes | Improved self care and self management, including better use of medications |
Potential benefits for health and social care commissioners, providers and the workforce
| Potential benefit | Achieved through care planning by… |
|---|---|
|
Focusing on personalisation and
outcomes. Meeting holistic needs and true discussion and engagement should promote more choice. Information from care plans can support needs assessment |
|
Having contingency planning, e.g. who
to contact, what to do in a crisis episode Increased self care and self management - there is evidence of reductions in GP and outpatient appointments Supporting people to be independent, better management of risk, and perhaps use of assistive technology to support people to live at home if that is one of their goals |
|
Having someone to lead on the care planning process and co-ordinate services can have a hugely positive impact for the person and their carer, particularly for people with a range of complex health and social care needs |
