Self Management Strategy & Personal Health Plans Dr Gerry McCabe GP & E&N Herts CCG Diabetes Lead

Self Management in LTCs Five Year Forward View Public Health Strategy in Hertfordshire Personal Health Planning

Self Management in LTCs Five Year Forward View Public Health Strategy in Hertfordshire Personal Health Planning

Five 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

Self Management in LTCs Five Year Forward View Public Health Strategy in Hertfordshire Personal Health Planning

Public 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

Public 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

Public 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

Self Management in LTCs Five Year Forward View Public Health Strategy in Hertfordshire Personal Health Planning

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.

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.

Why?

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.

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

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.

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

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

Self Management Strategy & Personal Health Plans Five Year Forward View Public Health Strategy in Hertfordshire Personal Health Planning Thank you - any questions?