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Guides to personalised care planning i.e. supporting people living with a long term condition to self care.
Eight Information Sheets have been produced by the Department of Health to support healthcare professionals implement personalised care planning as part of their management of people with a long term condition. They are intended for use by doctors, nurses, those delivering personal health budgets, allied health professionals and health trainers and anyone supporting individuals with long term conditions.
|Information Sheet Title||Contents|
|Personalised Care Planning||A description of what personalised care planning is and what good care planning looks like as well as what it means for individuals and healthcare professionals.|
|Personalised Care Planning Diagram||The care planning diagram takes the reader through the different stages of an individual’s journey when they have a long term condition, illustrated by real people case studies. The diagram includes information on the approaches and behaviours needed by a healthcare professional to deliver good personalised care. It can be used in conjunction with information sheet 1, Personalised care planning, or as a standalone document or wall chart.|
|Care Coordination||It describes the principles of care coordination and how an integrated approach is crucial to effective care delivery.|
|Assessment of Need and Managing Risk||It describes the links between assessment and personalised care planning and considers the risk involved in supporting individuals with complex health and social needs to achieve their goals and manage their condition(s) better.|
|What Motivates People to Self Care||Designed to give a brief overview of what motivates people to self care. It is intended to be an aid to reflective practice – to help healthcare professionals approach a self care discussion from the individual’s perspective.|
|Goal Setting and Action Planning||It describes some practical tips to support individuals to set their own goals as part of the care planning process.|
|How Information Supports Personalised Care Planning and Self Care||A description of the role of high quality, timely and relevant information in enabling a good care planning discussion and supporting self care.|
|End of Life Care and Personalised Care Planning||A focus on the principles of good end of life care for individuals with long term conditions and describes how it fits with assessment and personalised care planning.|
The patient journey should start with the Health Needs Assessment View - Download. The health needs assessment (HNA) is a tool that has been developed to assist patients to identify the things they require the most support with. It comprises of 24 generic questions and 15 questions that relate to long term conditions.
The NHA helps health professionals to identify the needs of the patient and target resources more effectively, offering a more personalised support to patients with chronic health conditions.
The HNA helps health professionals to identify the needs of the patient and target resources more effectively, offering a more personalised support to patients with chronic health conditions.
Clinical staff are encouraged to use the health needs assessment with patients to help them outline the problems that are important to them and which will impact on their lives and well-being. The HNA can also be used as part of the process of reviewing patients.
Accessible by Medical Practitioners
Electronic Learning for Health (e-lfh) www.e-lfh.org.uk
Personalised Care Planning
Accessible by NHS North Somerset and North Somerset Community Partnership
National Learning Management System via the electronic staff record.
The DH commissioned the Sector Skills Council partners (Skills for Health
and Skills for Care) to collaborate to develop a competence framework that
would describe the skills and knowledge required to support self care.
“Common Core Principles to Support Self Care” sets out 7 principles:
|Principle 1||Ensure individuals are able to make informed choices to manage their self care needs|
Communicate effectively to enable individuals to assess their needs, and develop and gain confidence to self care
|Principle 3||Support and enable individuals to access appropriate information to manage their self care needs|
Support and enable individuals to develop skills in self care
|Principle 5||Support and enable individuals to use technology to support self care|
|Principle 6||Advise individuals how to access support networks and participate in the planning, development and evaluation of services|
|Principle 7||Support and enable risk management and risk taking to maximise independence and choice.|