The Year of Care (YOC) Programme has shown how to deliver personalised care in routine practice for people with Long Term Conditions (LTCs), using diabetes as an exemplar. The approach puts people with LTCs firmly in the driving seat of their care and supports them to self manage their condition/s.
Implementing the approach in three diverse communities led to important learning for commissioners. This includes:
- A new commissioning model for LTCs. Introducing care planning and better self management at the centre of care for people with LTCs stimulated service redesign, new approaches to commissioning and whole system change, leading to better integration of services.
- A practical guide to commissioning and delivery of non traditional services to support self management through the third sector including the barriers and solutions.
Detailed practical information and the benefits for people with LTCs and clinicians (including general practitioner providers and commissioners) can be found in the key documents and summaries, available on the diabetes website. These include:
- Year of Care: Report of findings of the pilot programme
- Year of Care: Thanks for the Petunias: a guide to developing and commissioning non-traditional providers to support self management for people with long term conditions.
- Year of Care: Summary of key achievements and outputs
- Year of Care: Commissioning model for LTCs
- Year of Care: Workforce issues and service planning for people with LTCs
Fit with policy
Care planning provides a framework to support shared decision making and the policy imperative of ‘no decision about me without me’. The YOC approach addresses the three key drivers within the LTC QIPP programme and provides a gateway for the delivery of choice through personalisation, (personal health budgets), information prescriptions, tele-health and Any Qualified Provider (AQP).
The Royal College of General Practitioners (RCGP) has adopted the YOC approach as the practical base for its report on care planning Care Planning – Improving the Lives of People with Long Term Conditions
The College has appointed a clinical lead and plans to produce professional standards for care planning for inclusion in training and continuing medical education for GPs. Care planning based on a YOC approach is a quality standard for adults with diabetes prepared by NICE for the NHS Commissioning Board, and provides a service model for delivery of 9 of the 13 published standards.
The Year of Care Partnership can provide a range of resources and training to support local delivery of the programme
The YOC Training and Support Programme has developed a robust intervention via repeated rounds of testing and feedback across 15 sites, over 1000 practitioners and 40 quality assured trainers. The approach can be reproduced easily and has been transferred to COPD, health checks, cardiovascular disease and those with multi morbidity. The Programme is tailored to local requirements.
- Patient materials eg sample letters, information about results, care plans, awareness raising materials
- DVDs of awareness raising and consultation skills
- Guidance document: National Care Planning Training
- ‘Mind Your Language’
- Practice pack
- Evaluation framework and toolkit
- IT guidance for GP systems (EMIS, VISION, SystmOne)
Training curricula include:
- Taster sessions: Preparing for Care Planning
- Core care planning training
- Train the Trainer and quality assurance programme
- Healthcare Assistant training
- District Nurse training in care planning
- LTC care planning training for practice teams
- Training for integrated community teams – working with people with LTCs risk assessed as in the top 7% of the practice population as likely to use unscheduled care
- Extended consultation skills for clinical staff
- A programme to set up local mentoring and support to build confidence, embed and transfer skills and attitudes across the local community
How to contact the Programme
The Programme and the National Training and Support Team now make up Year of Care Partnerships based at Northumbria Healthcare Foundation Trust. They are working with local and national partners to make personalised care planning the norm for everyone with long term conditions and embed self management into routine NHS practice. They can be contacted at email@example.com.
The new website provides all the details about the Year of Care Programme, the impact, its fit with policy and new approaches to care for people with LTCs. www.diabetes.nhs.uk/year_of_care.