Care Planning

NICE quality standards for diabetes state that people with diabetes should participate in annual care planning which leads to documented agreed goals and an action plan.

Care planning is defined as a process that actively involves people in deciding, agreeing and sharing responsibility for how to manage their diabetes. It aims to help people with diabetes achieve optimal health by partnering with healthcare professionals to learn about, manage, and cope with diabetes and its related conditions in their daily lives.

Care planning is underpinned by the principles of patient-centeredness and partnership. It is an ongoing process of communication, negotiation and joint decision-making in which both the person with diabetes and the healthcare professional(s) make an equal contribution to the consultation. It offers people active involvement in decision making and is more likely to lead to successful self management strategies.

At each care planning consultation the healthcare professional(s) gives the patient the opportunity to:

  • share information about issues and concerns
  • share results of biomedical tests
  • discuss the experience of living with diabetes and address needs to manage obesity, food and physical activity
  • receive help to access support and services
  • agree a plan for managing diabetes
  • address individual priorities and goals.
  • identify priorities and/or goals that are jointly agreed including jointly setting a goal for HbA1c

identify detailed specific actions in response to identified priorities which include an agreed timescale.

Care planning incorporates:

  • nutritional advice
  • discussing psychological wellbeing
  • managing obesity
  • structured education
  • screening for complications
  • smoking cessation advice
  • physical activity
  • agreeing goals for HbA1c
  • agreeing plans for managing diabetes
  • discussing goals

In short the care planning process involves:

  1. Information gathering- the patient attends for annual complication screen including blood and urine tests, blood pressure and foot examination.
  2. Information sharing- the complication screen results are shared with the patient for consideration prior to the care planning appointment. The YourDiabetes care planning template includes some prompts and questions to encourage the patient to consider the results and other aspects of their diabetes prior to the consultation.
  3. Care planning consultation- with practice nurse or GP. This should include goal setting and action planning. Patients receiving Complex Care in the diabetes centre will also have appointments with the diabetes team and in some cases the primary care planning process for these complex patients may result in liaison with the diabetes team to expedite appointments where necessary.
  4. The agreed care plan is produced on the YourDIabetes template and shared with the patient.

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