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Diabetes care in Reading, Wokingham and West Berkshire

Preparation for Care Planning

How to prepare for Care Planning training and its implementation in practice

Preparation for Care Planning: pre-training

The 2013-14 Care Planning training courses are now completed.  There are further courses available funded by TVSCN, The next course in in early September 2016 and places can be booked through

For the practices keen to get started with making changes this feels too long to wait.  The good news is there is pre-course preparation work to be done that if completed through the following months will make for a much smoother implementation process.

This document gives practices guidance as to the ground work required and questions to be answered in order to implement care planning.

Understanding the philosophy behind Care Planning and Year of Care (YOC) is critical. The YOC website is an invaluable resource offering information for health care professionals and patients alike.

Initial practice meetingWho from your practice team needs to be involved in implementing care planning? Which GP’s, Practice Nurse, HCA, admin? Representatives from each area should attend the meeting.

View the processes required to implement care planning and explore House Model.

Year of Care Care Planning House Model.

Care planning house image

Main principles of Care Planning.

  • It enhances the routine biomedical surveillance and ‘QOF review’ with a collaborative consultation, based on shared decision making and self management support, via care planning
  • Ensures there is a choice of local services people need to support the actions they want to take to improve their health, wellbeing and  health outcomes, available through commissioning
  • Commissioning will be based on patients’ needs.


Understanding the Care planning  process and how it can be achieved

Care planning process diagram

Some questions and challenges to be addressed.

Explore the role of the HCA

  • Who is going to do it, when and where?
  • How much time do we need to perform the checks?
  • How can this role be developed. Any further training required to fulfil the role. Podiatry training, phlebotomy, meter training.  Understanding of local services for sign-posting.
  • Devise protocols for abnormal findings i.e high BP, very low mood.


  • Who is going to collate the results and send to patients?
  • How much time is required?
  • Encourage patient portal and e-mail.

Preparing the patient

Devise a letter to patients explaining the changes in the annual review process and the reasons why.

What information and parameters will you include in your results letter? e.g Higher and lower targets for BP, Hba1c, kidney function.

Include important terminology e.g.: Joint decisions, agreement on diabetes management, sharing results and preparing prior to annual review. Self management.

Consultation skills

This may feel a little daunting without the formal training. The consultation skills will be addressed with opportunity to practice during the training. By just sending the results in advance and allowing the patient time to prepare the dynamic of the consultation will immediately change. Having some experience of this style of consultation will help when you come to formally train. Use crib sheet encouraging patient to explore own goals and develop own action plan. Use this time to reflect on current consultation style. Who does most of the talking?

Switching to Care Planning takes time and the skills will evolve slowly. Thinking about some of the organisational aspects and the philosophy behind care planning will provide good foundations from which to build on and will provide essential pre-implementation preparation