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There are real opportunities to address this, such as this integrated care plan.
Key objectives
All people with SMI should be offered an annual physical health check within Primary Care (their GP). This will measure and record information on smoking, obesity and high blood pressure on EMIS, which will be visible on the person’s Patients Know Best record.
Where such conditions are found, the person with SMI should be offered appropriate support and treatment, which they can set out in their ‘Me and My Goals’ plan, and continue to track their health and wellbeing by recording their measurements independently.
Outcome measures
Every person will be able to see their physical health check data and use their digital care plan ‘Me and My Goals’ to identify their health and well-being priorities (‘what matters to me’). They can also set out their personalised recovery plan with support from healthcare professionals involved in their care.
When invited by the person, professionals from the wider framework of recovery services will be able to see this physical health check data and digital recovery plan and give guidance and support as appropriate to their role and relationship to the person.
Current Baselines
All activity is face to face, with a lot of patients travelling large distances, where the follow-ups aren’t being efficiently or effectively managed.
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Patients often feel once they have received a diagnosis for their mental illness, their physical health is neglected. Additionally, they can experience stigma and communication difficulties affecting their ability to seek medical help.
Workflow
Patient: Attends physical health check appointment.
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Patient: continues to use PKB to track progress, update steps for achieving goals set out in their ‘Me and My Goals’ plan, and communicate with GP/Health Care Assistant etc to record and self-manage their recovery and wellbeing.
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Me and my goals care plan template
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<div class="form-inline"> <style media="screen"> a {word-wrap: break-word;} .form-group {width: 100%; !important} .cp_label {font-size: 18px;font-weight: 900;} .cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px;} </style> <div class="cp_whiteBox"> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <label class="cp_label" for="cp_aboutMe">About Me</label> <p>Use this space to record your story and what is important to you.</p> <textarea class="form-control" name="cp_aboutMe" id="cp_aboutMe" rows="5" style="width: 100%;"></textarea> </div> </div> <br /><br /> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <h3>My Recovery Goals</h3> <p>Thinking about your mental health, physical health and social needs write down up to three goals that you want to achieve to get well and stay well. Under each goal write down the step you need to take to achieve the goal and the date you hope to do it by.</p> </div> </div> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <label class="cp_label" for="cp_goal1">Goal No 1</label> <textarea class="form-control" name="cp_goal1" id="cp_goal1" rows="1" style="width: 100%;"></textarea> </div> </div> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <label class="cp_label" for="cp_nextstep1">My next step</label> <textarea class="form-control" name="cp_nextstep1" id="cp_nextstep1" rows="3" style="width: 100%;"></textarea> </div> </div> <br /> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <label class="cp_label" for="cp_goal2">Goal No 2</label> <textarea class="form-control" name="cp_goal2" id="cp_goal2" rows="1" style="width: 100%;"></textarea> </div> </div> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <label class="cp_label" for="cp_nextstep2">My next step</label> <textarea class="form-control" name="cp_nextstep2" id="cp_nextstep2" rows="3" style="width: 100%;"></textarea> </div> </div> <br /> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <label class="cp_label" for="cp_goal3">Goal No 3</label> <textarea class="form-control" name="cp_goal3" id="cp_goal3" rows="1" style="width: 100%;"></textarea> </div> </div> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <label class="cp_label" for="cp_nextstep3">My next step</label> <textarea class="form-control" name="cp_nextstep3" id="cp_nextstep3" rows="3" style="width: 100%;"></textarea> </div> </div> </div> </div> |