Care and Support Planning for Patients with Long Term Conditions

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We have changed the way we organise appointments and provide support for people with long term conditions (such as heart disease, diabetes, COPD), by putting in place a new way of working called care and support planning.

What is care and support plannning? This way of working aims to give you the opportunity to get more out of your annual review appointments by reorganising the way things happen and giving you more information before you see your nurse or doctor. It should help you to talk about;

  • What is important to you
  • What you can do to look after your health and stay well
  • What support you may need

Who is it for? Anyone with a long term condition, including diabetes, heart disease and previous strokes.

Why change things? This way of working is being put in place across a number of surgeries in the area, and is nearly always preferred by patients. It will help both you and the doctor or nurse to make the best use of the time you have in your care and support planning appointment. All the important tests and results needed at your appointment will be available to you as well as your doctor/ nurse before the appointment. This will give you a chance to think through what questions you want to ask, what things mean and identify your key concerns which you want to talk about.

What does this mean for me? This means that your care and support planning review will usually take place over two seperate appointments and you will need to think about what you want to get out of these visits.

What happens at the first appointment? This will usually be in your birthday month - you will be asked to attend the surgery to have any checks or tests (e.g. blood tests, breathing tests) done with a healthcare assistant or nurse.

What happens next? Some of your test results from this appointment will be sent to you with an explaination of what they mean, on a yellow sheet of paper. There will also be a space on the letter for you to make notes along with the details for your next appointment and who you will be seeing. This will give you a chance to think about what you would like to talk about at your care and support planning appointment (your second appointment). It's helpful if you bring this yellow letter to your care and support planning appointment.

What happens at the care and support planning appointment? At your care and support planning appointment you will be able to ask questions and talk about what's important to you, and your doctor or nurse will raise any issues they are concerned about. Once you both agree on one or two priorities, you will get the chance to work out a plan and identify any support you need to help look after your health. We will aim to review all of your conditions/problems and medication, so we make these appointments longer than the usual 10 minutes – most care planning appointments are 20 minutes long but we allow more time than this if it is needed.

Before you go we will clarify when your next review will be – if you have diabetes you will continue to have one or two “checks” a year in the usual way, but this care planning appointment will replace what we used to call your annual review.

We have been running the clinic in this way since June 2015 and have had lots of very positive feedback. In fact we have had visitors from as far away as Thames Valley coming to the practice to find out about our system and how we run these clinics. If you have any questions or comments we would be really glad to hear from you – please telephone Glenpark and ask to speak to Jenny or Chelsea, or drop us a line or contact us via the website.