Diabetes MCN 24 November 2016 Carl Bickler and Rachel Hardie House of Care Diabetes MCN 24 November 2016 Carl Bickler and Rachel Hardie

RH introduce house

House of care ‘metaphor’ Patient centred –good conversations Trained staff Engaged, enabled and supported patients and carers Improving patients ability to self manage-Diabetes My Way and others Appropriate ‘processes’ Support the services patients ‘need’

House of Care and Diabetes general practice pathway

‘Data’, patient activation and care planning Patient invited-informed, encouraged and activated Health care assistant appointment Biomedical tests and measurements process explained further Information sent out Care planning appt –practice nurse Care plan Action plan Repeat cycle

Diabetes and house of care Edinburgh 12 month project 6 practices Diabetes/multiple morbidity 2 stage process Year of Care training and other training support Redesign processes learning cycles Start with small numbers Evaluation-self management, patient activation, professional view, patient view.

“It” works – Year of Care Impact on people – quality of life, biomedical outcomes Impact on primary care ? change in pattern Impact on workforce

“It works” – the components Supported self-management Shared decision making