Example Total number of patients Number with a care plan Number without a care plan 100 20 80 New care plans = 70% (of 80) = 56 care plans Review of care = 30% (of 20)= 6 care plans 2) Completing Care Plans 2.1 Which Care Plan? SystmOne - Ardens Users SystmOne - Non Ardens EMIS Web Users Use the relevant condition Continue to use the Continue to use the same specific templates to capture key same Personal Care Personal Care Plan that information. Plan that you used for you used for 17/18 and 17/18 and have used in have used in previous Use the LTC review template to previous years as part of years as part of the help you identify which condition the avoiding unplanned avoiding unplanned specific plans the patient needs. admissions DES. admissions DES. Click on future care planning Click on Generic Care Plan Ensure patients are Ensure patients are (This is the foundation correctly coded with a correctly coded with a GSF document) - make sure you GSF stage / Frailty code, stage / Frailty code, where where appropriate. appropriate. select the code from the drop down box Signpost patients (where Signpost patients (where Click on Specific Care plan - appropriate) to appropriate) to this will take you to the support on support on plans for the Health in Herts the Health in Herts specific conditions webpages. webpages. Signpost patients (where For end of life patients: For end of life patients: Ask appropriate) to self-management Ask for consent to add for consent to add support on the Health in Herts information to the information to the summary webpages summary care record. care record. Use the Use the EPaCCS leaflet EPaCCS leaflet For end of life patients: Ask for to explain how this works consent to add information to the summary care record. Use the EPaCCS leaflet Further step by step guidance can be on the CCG website
Total number of patients Number with a care plan Number without a care plan 100 20 80 Example New care plans = 70% (of 80) = 56 care plans Review of care = 30% (of 20)= 6 care plans 2) Completing Care Plans 2.1 Which Care Plan? SystmOne - Ardens Users SystmOne - Non Ardens Users EMIS Web Use the relevant condition specific templates to capture key information. Use the LTC review template to help you identify which condition specific plans the patient needs. Click on future care planning Click on Generic Care Plan (This is the foundation document) - make sure you select the code from the drop down box Click on Specific Care plan - this will take you to the plans for specific conditions Signpost patients (where appropriate) to self-management support on the Health in Herts webpages For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet Further step by step guidance can be on the CCG website Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Ensure patients are correctly coded with a GSF stage / Frailty code, where appropriate. Signpost patients (where appropriate) to support on the Health in Herts webpages. For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet to explain how this works Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Ensure patients are correctly coded with a GSF stage / Frailty code, where appropriate. Signpost patients (where appropriate) to support on the Health in Herts webpages. For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet
Item%20D1%20-%20Care%20Planning%20Guidance.docx