Jim completed the personal care and support planning discussion and his personal budget was agreed by the team social worker. An initial review of this was put in place with his 'key worker' (and his daughter) after six weeks, when minor modifications were made. A regular, person-centred review was then scheduled for six month's time. As a result Jim is now getting more involved in the church.
Jim also sees his GP at agreed times linked to health care assistant appointments, where tests and health assessments are repeated as necessary prior to a further discussion. This is an opportunity to check that everything is going well and Jim's overall outcomes are being met.
The GP answers Jim's questions about his health and they think through advanced planning, what he would like to happen if his health gets worse slowly or suddenly. This is recorded so that it is accessible at the right time to the right people such as ambulance staff.