Transcript personal health plans - NHS East and North Hertfordshire Clinical

Self Management Strategy &
Personal Health Plans
Dr Gerry McCabe
GP & E&N Herts CCG Diabetes Lead
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Self Management in LTCs

Five Year Forward View

Public Health Strategy in Hertfordshire

Personal Health Planning
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Self Management in LTCs

Five Year Forward View

Public Health Strategy in Hertfordshire

Personal Health Planning
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Five Year Forward View (Oct
2014)

Emphasis on prevention and self management
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LTCs are a central task of the NHS
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People with LTCs spend < 1% of their time with Health
Care Professionals
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They otherwise self manage
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Empower patients:

Improve access to better information

Support people to manage their own health
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Self Management in LTCs

Five Year Forward View

Public Health Strategy in Hertfordshire

Personal Health Planning
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Public Health Strategy
in Hertfordshire

Self Management Steering Group - 4 Areas
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Embed skills to support self management in the workforce
& among patients & carers
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Develop the role of Community Pharmacy
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Support self management outside the NHS (social care
and voluntary sector)
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Embed risk stratification into self management pathways
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Public Health Strategy
in Hertfordshire
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Embed skills to support self management in the
workforce & among patients & carers
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Funding bid for pilot schemes in E&N Herts and Herts
Valleys CCGs
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Use psychology expertise
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Change the way that health professionals work
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Change the way that patients respond to their LTCs
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Public Health Strategy
in Hertfordshire

Embed skills to support self management in the
workforce & among patients & carers
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Do Something Different
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Behaviour change pilot programme for Type 2 DM
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Email / text message over a 6 week period to support
change in established behaviours
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Self Management in LTCs

Five Year Forward View

Public Health Strategy in Hertfordshire

Personal Health Planning
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Personal Health Planning
Coalition for Collaborative Care 2014
Personalised care and support
planning encourages care
professionals and people with LTCs
to work together to clarify and
understand what is important to
that individual.
They agree goals, identify support
needs,
develop and implement action
plans, and monitor progress. This is
a planned and continuous process,
not a one-off event.
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VISION
 To
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develop an integrated care plan, used by
all providers called ‘My Personal Health Plan’,
to ensure that people are involved in
managing their condition, receive the care
they need to live and die well, and that both
they and their carers feel better supported to
maintain a good quality of life.
Why?
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Why?
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
Patients with multiple LTCs are on the rise and we need a more
holistic approach to meet their needs
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Patients with multi-morbidity end up with many care plans that
do not work for them or their clinicians
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Variation in delivery of care plans across the CCG
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Not person-centred-more disease specific
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Evidence suggests it leads to more appropriate use of
resources,people more engaged and can self-manage more
effectively and adopt a more healthy lifestyle.
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Need better integrated approach with whole system buy-in so all
health and social care professionals are involved.
BENEFITS TO PEOPLE
WITH LTCs
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Involvement in the decision making process
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Better understanding of their condition
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Develop ability/increase in confidence to self manage
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Provide consistency and continuity of care
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Information and sign posting to local services
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Opportunity to have a central role in service planning,
and agreeing what local care should look like

Involving carers more in regards to identifying and
supporting their health and care needs
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BENEFITS TO CLINICIANS

More satisfying consultations
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See better outcomes for people with LTCs
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New skill set if it is to be truly integrated.
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A lever to drive quality
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Less inappropriate use of medications
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To test services commissioned that people with LTCs
will use.
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BENEFITS TO
COMMISSIONERS
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
Greater value for money by improving health outcomes and reduce
waste
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Positive impact on patient experience such as prevent unplanned
care.
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Provides information needed to commission services that people
want and clinicians value
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Fits very well with integration agenda and will add value to HomeFirst
Plus
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Provides sustainable, long term approach to reducing the burden of
LTCs on local resources
My Personal Health Plan
- a work in progress...
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About Me
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Medical Information
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My Preferences
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My health action plan
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What to do if I become poorly
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Additional information and ownership
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Contacts and useful information
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My notes
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Self Management Strategy &
Personal Health Plans

Five Year Forward View

Public Health Strategy in Hertfordshire

Personal Health Planning

Thank you - any questions?
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