Preparation for the process:
Jim is contacted by phone from the GP-based, multi-disciplinary team and offered the opportunity to develop a personalised care and support plan. This will allow Jim to have significant input into how his needs are met and the coordination of all his interactions with health and social care through a single plan based on what he thinks is important.
- Jim is happy to take part because he is fed up with multiple people who he doesn't really know coming into the house. He is also worried that his daughter is now having to take time off work to stay with him.
- He is asked about how he wants information and asks for it to be in writing. He is also asked if he would like help to complete this, but Jim says he can do so with his daughter and gives the best times for visits and appointments so that she can be there.
- The district nurse asks to take blood tests next time she comes and Jim is happy to allow this, as she does it to support his drug therapy anyway.
- He doesn't mind who he talks to, as he doesn't know one person from another, but is glad to hear that in the future one person will be involved in all the conversations.
Preparation by the practitioner:
The social workers in the multi-disciplinary team ensure that the financial assessment documents are included in Jim's letter for self-completion.
The GP identifies which blood tests are needed and adds that to the district nurse's task list. S/he has also reviewed all the notes and previous letters from the hospital and realises that the cardiology clinics are not important and that some of his drugs may be making him unsteady.
Preparation by Jim:
When Jim receives the letter and prompts he sits down with his daughter and goes through it, spending some time reflecting on what is important to him now and what he would like life to be like in six months/a years time.
He also fills in the individual financial self-assessments. He has several things he wants to ask the GP about the number of drugs he is taking and his daughter wants to discuss his care with the social worker.
Personal care and support planning for people with complex health needs is often planned more proactively (not in a crisis) by the practice and may include a visit at home from a volunteer to get to know Jim better and be a constant over the next few years, keeping an eye on his overall health.