1. Goal Setting and Action Planning Workshop
Dr Hannah Robertson, Consultant Physician, Clinical Lead for Supported Self-Management
Kirsteen Coady QN, ANP Macduff, NES Educational Advisor and Supervisor,
Alison Hannan - Public Health Practitioner-Advanced and Project Manager for Grampian House of Care
Introduce ourselves and ask the group who they are and representing and what they would like to get out of the next 45mins
Explain where Goal Setting and Action Planning fit in with House of Care Training – Care and Support Planning..

2. House of Care
At the centre is the conversation between the patient and their healthcare professional.
The roof is made of organisational and clinical processes to be put into place.
The right wall is a commitment from the Health and Care Team to partnership working and being trained.
The left wall is an engaged, informed and empowered patient.
The floor is the variety amount of formal and informal sources of care that are available to the patient within their community.

3. Care and support planning: the process
Recording the agreed & shared care plan
Information gathering
The conversation
Information sharing
Disease surveillance
Tests and checks
performed where needed
Preparation
Results/agenda setting prompts
sent to patient > 1 week before
conversation
Conversation
A meeting of equals and experts
Prepared practitioner and patient:
review how things are going
consider what's important
share ideas
discuss options
develop a care plan

4. Care and support planning conversation
Recording the agreed & shared care plan
Information gathering
The conversation
Information sharing
Planning for review
Action planning
Goal setting
Explore and discuss
Gather and share stories
Consultation done as partners and equals to decide on goal.
NOT– Professional ‘telling’ person with LTC what the goal is.
Come to the point of goal setting/action planning by exploring what matters to the person and how it fits with their longer term aims 4

5. House of Care
At the centre is the conversation between the patient and their healthcare professional.
The roof is made of organisational and clinical processes to be put into place.
The right wall is a commitment from the Health and Care Team to partnership working and being trained.
The left wall is an engaged, informed and empowered patient.
The floor is the variety amount of formal and informal sources of care that are available to the patient within their community.

6. Think of a personal goal you are willing to share to the group that you would like to achieve over the next 6-12months

7. Specific Measurable Achievable Realistic Time Focused
SMART Objectives
Specific Measurable Achievable Realistic Time Focused

8. Share about SMART Objectives

9. LOW HIGH Impact on Readiness HIGH LOW IMPORTANCE CONFIDENCE
Share that people come into the practice may be at different stages in their outlook on life and some will be very confident some won’t be others it will be very important to reach a particular goal while others it won’t be important to them.
LOW

10. IMPORTANCE HIGH LOW CONFIDENCE HIGH LOW
Ready to go – confirm the detail
Checking/clarifying the plan – how SMART?
Checking skills and knowledge
Thinking about barriers and support
Maintenance/prevent relapse
Safety netting
Explore and discuss
Ambivalence
Risk – “personally relevant”
Health beliefs
Health Education – drip feeding
Discuss feelings about health and wellbeing
Confirm importance
Focus on practical solutions they identify
Explore support – including family/peers/non traditional
Action plan – small steps
Exploring previous experiences
Seeing someone like you do it!’
Anxiety/low mood
Explore and discuss ideas
Explore mood
Work on a different goal
Explore the pros and cons
Reflect on the consequences of maintaining the status quo
No nagging
CONFIDENCE
HIGH
LOW

11. Goal setting exercise
What do I need to be able to do differently to be able to deliver care and support planning?
What steps do I need to take to achieve this?
What does my practice need to do differently to be able to deliver care and support planning?
What steps do we need to take to achieve this?
Write down a plan of the next steps for your practice.
Give each of these a time frame, a level of confidence and level of importance.
Working together and action planning in practice groups for just 10 minutes:
Initially as individuals (3 minutes) and then in your practice group (7 minutes) think about
What do I need to be able to do differently to be able to deliver Care Planning?
What steps do I need to take to achieve this?
What does my practice need to do differently to be able to deliver Care Planning?
What steps do we need to take to achieve this?
Jointly, write down a plan of the next steps. Make sure you give each of these a time frame, a level of confidence and level of importance.
Sharing plans – ask permission to share then use a flipchart to get very quick feedback about the next steps that each practice group will take. This will be fed back to the group after the training event.

12. Next steps….
What learning do you think you need to take forward to further your consultation skills?
What one thing do you hope to do differently?
What is your next step?