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

Abstract

Background: People 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’. Methods: The 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. Results: The 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. Conclusions: Tested 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.

The Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) protocol: a non-randomised controlled trial of personalised care and support planning for persons living with diabetes

“…Persons with LTCs have important roles in managing their own health in the context of their daily lives, but often need support, including to develop the confidence and skills to adhere to medications, adopt and maintain healthy lifestyles, and know when and how to seek medical advice. Personalised care and support planning (CSP) has been proposed as a means to provide support from healthcare providers (HCPs) that is individualised to the needs of specific persons with LTCs and oriented to enable them not just to manage their LTCs well in biomedical terms but more broadly to live well with those LTCs [11,12]. Personalised CSP entails a conversation or a series of conversations between the patient and the HCP when they jointly agree on goals and actions for managing the patient's health problems [11,12].…”

“…Personalised care and support planning (CSP) has been proposed as a means to provide support from healthcare providers (HCPs) that is individualised to the needs of specific persons with LTCs and oriented to enable them not just to manage their LTCs well in biomedical terms but more broadly to live well with those LTCs [11,12]. Personalised CSP entails a conversation or a series of conversations between the patient and the HCP when they jointly agree on goals and actions for managing the patient's health problems [11,12]. Evidence shows that personalised care planning, most effective when integrated in routine clinical practice, leads to improvements in certain indicators of physical and psychological health status of patients, and their capability to self-manage their condition as compared to usual care [11,12].…”

“…Personalised CSP entails a conversation or a series of conversations between the patient and the HCP when they jointly agree on goals and actions for managing the patient's health problems [11,12]. Evidence shows that personalised care planning, most effective when integrated in routine clinical practice, leads to improvements in certain indicators of physical and psychological health status of patients, and their capability to self-manage their condition as compared to usual care [11,12].…”

“…Year of Care Partnerships (YoC) in the United Kingdom (UK) has implemented and made iterative changes in the use of CSP for over a decade [11,12]. The personalised CSP has been conceptualised as a meaningful conversation between partners that occurs within a "house of care" [13] with four components: The prepared person living with diabetes and the trained CSP practitioner form each of two walls of the house, the organisational processes that operationalise the CSP form the roof, while institutional support forms its foundation.…”

“…Explicit orientation of care to support personal goals in CSPs was observed to raise practitioner morale and strengthen the practitioner-patient relationship; ripple-effects have been seen at the organisational level with improved levels of productivity at zero additional cost [7,13]. As a further badge of its success, CSP practice has spread to multiple sites across England and Scotland, [11] and CSPs have been adopted as part of the core curriculum in General Practice training in the Royal College of General Practitioners (RCGP) since 2019 [14].…”