Examples and case studies
Year of Care Partnerships have now worked with a number of organisations to implement care and support planning in a variety of settings and with different conditions. This includes diabetes, multiple long term conditions within a Primary Care setting and multimorbidity / older people living with frailty. The Year of Care case studies provides examples of how this was achieved.
In June 2018 Year of Care jointly presented a poster with Newcastle Gateshead CCG at the Kings Fund event 'Reimagining General Practice' on the fantastic work that the CCG has supported and is continuing to support for people living with long term conditions and multimorbidity. You can see the poster here. The poster describes how collaborative care and support planning has been used to stimulate redesign of general practice care for people living with long term conditions and multimorbidity across the CCG.
12 months ago Carlisle Healthcare embarked upon their implementation of an integrated approach to personalised care and support planning (CSP) for those with multi-morbidity and frailty who would otherwise be unable to attend their usual surgery for routine care. This built on an established approach to care and support planning for people with long term conditions who would usually attend the practice for their care. To read more about this please see The Carlisle Story or watch Dr Robert Westgate describe the approach at Carlisle Healthcare here.
The Holmside Story and Glenpark Story illustrate how two practices have implemented care and support planning for their long term condition population ensuring that individuals who have multiple conditions do not have separate disease specific care planning appointments.
Dr Becky Haines is a GP from Glenpark Medical Centre and delivered a keynote speech at the Year of Care Community of Practice Network Event in June 2016. She discussed how the practice decided to implement care and support planning and the journey they have been on ever since. To see a summary of some of the main points Becky raised please click the link below:
Tower Hamlets were one of the original Year of Care pilot sites. GP and clinical lead Isabel Hodkinson describes the Tower Hamlets story in this video.
CSP and Adult Weight Management service
The recommissioning of the tier 3 specialist adult weight management (AWM) service in North Tyneside in 2014 provided the opportunity to redesign a more flexible person centred service that incorporated the principles of preparation for a better conversation in addition to a goal setting and action planning approach as promoted by Year of Care Partnerships (YOCP). Please click here to read about how the service was redesigned to better meet the needs of its users following a care and support planning approach.