The Year of Care approach: developing a model and delivery programme for care and support planning in long term conditions within general practice

Abstract

BackgroundPeople with long term conditions (LTCs) make most of the daily decisions and carry out the activities which affect their health and quality of life. Only a fraction of each contact with a health care professional (HCP) is spent supporting this.This paper describes how care and support planning (CSP) and an implementation framework to redesign services, were developed to address this in UK general practice. Focussed on what is important to each individual, CSP brings together traditional clinical issues and the person’s lived experience in a solution focussed, forward looking conversation with an emphasis on ‘people not diseases’.MethodsThe components of CSP were developed in three health communities using diabetes as an exemplar. This model was extended and refined for other single conditions and multimorbidity across 40 sites and two nations, over 15 years. Working with local teams and communities the authors used theoretical models of care, implementation and spread, developing and tailoring training, support and resources to embed CSP as usual care, sharing learning across a community of practice.ResultsThe purpose, content, process, developmental hurdles and impact of this CSP model are described, alongside an implementation strategy. There is now a robust, reproducible five step model; preparation, conversation, recording, actions and review. Uniquely, preparation, involving information sharing with time for reflection, enables an uncluttered conversation with a professional focussed on what is important to each person. The components of the Year of Care House act as a checklist for implementation, a metaphor for their interdependence and a flexible framework. Spreading CSP involved developing exemplar practices and building capacity across local health communities. These reported improved patient experience, practitioner job satisfaction, health behaviours and outcomes, teamwork, practice organisation, resource use, and links with wider community activities.ConclusionsTested in multiple settings, CSP is a reproducible and practical model of planned care applicable to all LTCs, with the capacity to be transformative for people with LTCs and health care professionals. It recaptures relational dimensions of care with transactional elements in the background. Options for applying this model and implementation framework at scale now need to be explored.

Health Complexity Assessment in Primary Care: a validity and feasibility study of the INTERMED tool

“…With nearly half of the sample being multimorbid, yet overall 18.3% found to be "complex", when adopting a personalizedbiopsychosocial lens, this study supports the notion that in practical terms defining PHC patient complexity as morbidity alone is inadequate(4-6,69). Instead, we support an increasingly recommended PHC person-centered planning including biopsychosocial (comprehensive) health risk assessment (1,8,55,56,(62)(63)(64)(65)(66)(67)(68), which can facilitate an better integration of care and a decrease in the cost of the health network (10,70). INTERMED could enable this approach once its predictive validity and feasibility from PHC teams' perspective is confirmed.…”

“…organization and coordination, service access, treatment experience) (4,6,7). Such knowledge can help to target those in need for advanced care planning, and effectively develop, coordinate and monitor those plans (1,7,8).…”

Needs and preferences of patients regarding atopic dermatitis care in the era of new therapeutic options: a qualitative study

“…This would facilitate in making “fair” choices, in particular for expensive therapies [ 8 , 41 ]. Agencies such as the FDA and the NHS also promote patient-centered care, with improved patient access to more affordable drugs [ 43 – 45 ]. In addition to patient-centered care (i.e., care that is respectful of, and responsive to, individual patient’s preferences, needs, and values) [ 46 ], personalized medicine (i.e., tailoring care based on patients’ genetic information or other biomarkers) [ 47 ] is also considered important to achieve individualized care [ 48 ].…”

Health complexity assessment in primary care: A validity and feasibility study of the INTERMED tool

“…These factors interact dynamically and non-linearly in an idiosyncratic manner for each individual [2][3][4]. The importance of incorporating the assessment of health complexity into the management of PHC patients for delivering high-quality care with desirable outcomes is increasingly recognized worldwide [5][6][7]. This is particularly critical in PHC settings that include one of the most medically and socially vulnerable groups of patients in the world, such as Brazil [5].…”