1Self Management Strategy & Personal Health Plans

Dr Gerry McCabeGP & E&N Herts CCG Diabetes Lead

2Self Management in LTCs

Five Year Forward View

Public Health Strategy in Hertfordshire

Personal Health Planning

3Self Management in LTCs

Five Year Forward View

Public Health Strategy in Hertfordshire

Personal Health Planning

4Five Year Forward View (Oct 2014)

Emphasis on prevention and self management

LTCs are a central task of the NHS

People with LTCs spend < 1% of their time with Health Care Professionals

They otherwise self manage

Empower patients: Improve access to better information

Support people to manage their own health

5Self Management in LTCs

Five Year Forward View

Public Health Strategy in Hertfordshire

Personal Health Planning

6Public Health Strategy in Hertfordshire

Self Management Steering Group - 4 Areas Embed skills to support self management in the

workforce & among patients & carers

Develop the role of Community Pharmacy

Support self management outside the NHS (social care and voluntary sector)

Embed risk stratification into self management pathways

7Public Health Strategy in Hertfordshire

Embed skills to support self management in the workforce & among patients & carers Funding bid for pilot schemes in E&N Herts and

Herts Valleys CCGs

Use psychology expertise

Change the way that health professionals work

Change the way that patients respond to their LTCs

8Public Health Strategy in Hertfordshire

Embed skills to support self management in the workforce & among patients & carers Do Something Different

Behaviour change pilot programme for Type 2 DM

Email / text message over a 6 week period to support change in established behaviours

9Self 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 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.

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Why?

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Why?

Patients with multiple LTCs are on the rise and we need a more holistic approach to meet their needs

Patients with multi-morbidity end up with many care plans that do not work for them or their clinicians

Variation in delivery of care plans across the CCG

Not person-centred-more disease specific

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.

Need better integrated approach with whole system buy-in so all health and social care professionals are involved.

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BENEFITS TO PEOPLE WITH LTCs

Involvement in the decision making process Better understanding of their condition Develop ability/increase in confidence to self

manage Provide consistency and continuity of care Information and sign posting to local services 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

See better outcomes for people with LTCs

New skill set if it is to be truly integrated.

A lever to drive quality

Less inappropriate use of medications

To test services commissioned that people with LTCs will use.

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BENEFITS TO COMMISSIONERS

Greater value for money by improving health outcomes and reduce waste

Positive impact on patient experience such as prevent unplanned care.

Provides information needed to commission services that people want and clinicians value

Fits very well with integration agenda and will add value to HomeFirst Plus

Provides sustainable, long term approach to reducing the burden of LTCs on local resources

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My Personal Health Plan- a work in progress...

About Me

Medical Information

My Preferences

My health action plan

What to do if I become poorly

Additional information and ownership

Contacts and useful information

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?