Comment

Why we need to plan

Elisabeth Bryant

People with several long term conditions may spend only four hours a year with any health professional. Who manages their conditions for the other 8756 hours? They do. Self-management has always happened.

Health professionals need to make time to listen, identify the patients concerns, and involve them in management decisions. Care and Support Planning (CSP), developed by the Year of Care Project, aims to enable people to choose how to manage their health with collaborative consultation and support.

How does it work?

The patient attends an annual data gathering appointment with a healthcare assistant, where relevant measurements are taken, and the process is explained. A patient with COPD may perform spirometry, someone with diabetes will have blood tests and foot screening, and someone with left ventricular systolic dysfunction will undergo an ECG. The results are sent to the patient in advance of

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People with several long term conditions may spend only four hours a year with any health professional. Who manages their conditions for the other 8756 hours? They do. Self-management has always happened.

Health professionals need to make time to listen, identify the patient’s concerns, and involve them in management decisions. Care and Support Planning (CSP), developed by the Year of Care Project, aims to enable people to choose how to manage their health with collaborative consultation and support.

How does it work?

The patient attends an annual data gathering appointment with a healthcare assistant, where relevant measurements are taken, and the process is explained. A patient with COPD may perform spirometry, someone with diabetes will have blood tests and foot screening, and someone with left ventricular systolic dysfunction will undergo an ECG. The results are sent to the patient in advance of the CSP appointment, with an explanation of meaning. The letter prompts for areas of concern such as poor sleep, increasing weight or low mood.

At the CSP consultation both participants have the data in advance. This allows the patient time to think what to ask about, and frees up discussion and exploration time. Together they can formulate a plan. This may involve reading about sleep patterns, trying a walking group or a change in blood pressure medication, or a further discussion in three weeks’ time. People bring their own health and leave with their own plan.

Plans need to be implemented to be effective. Access to local resources such as slimming clubs, health coaches and community cafes improve the likelihood of change. Ultimately individual plans should drive commissioning in the community, so that it becomes people and patient-centred.

Feedback

Patients said: ‘I had some time to think about things’,

‘It helped me raise things I was worried about’ and ‘you may not have all the answers but you’ve helped me work things out’.

A clinician said: ‘Absolutely 100% better than it was, for me and the patients’. 

 

You can find out more by visiting the website


About the author

Elisabeth Bryant is a nurse practitioner and care and support planning trainer in Gateshead, Tyne and Wear

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