Delivering care planning
Care and support planning and support for self management should be seen as core components of routine care, delivered by a workforce with the right skills and attitudes within a system that is designed around a personalised approach coordinated and based on the individual’s needs.
The house provides the framework for delivering services for people with long term conditions and is flexible to local circumstances. It illustrates that only by incorporating the whole system will the experiences, health outcomes and utility of healthcare for this group of people improve.
This requires signing up to a new way of working, not only within primary care, but also across traditional healthcare divides; and it offers a method of integrating community, primary care, specialist and secondary care services.
There needs to be strong clinical and managerial leadership to support this approach including engaging and supporting clinicians to work differently. Individual practices will find some of the challenges associated with implementing care and support planning difficult to overcome, however we have developed and continue to develop resources to help with this.
Local practice support and facilitation is also crucial and can make a difference in terms of truly embedding this approach. This can often be provided by locally trained trainers. The team have experience in this too and can offer varying degrees of support for you depending on your needs and geographical location.
We can offer help and support drawing on the experiences of the pilot sites and other communities who have built on this learning.