Table of Contents

NHS England reports that people with severe mental illness (SMI) have on average 15 to 20 years shorter life expectancy than the general population.

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 wellbeing 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.

Patients do not have a copy of their physical health check, and this information is not always visible to other wellbeing well-being and recovery services supporting the person to get well and stay well.

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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title	Example care plan template HTML code for Me and my physical health check care plan

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>

<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>

</div>

<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>

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</div>

</div>

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Versions Compared

Old Version 2

New Version Current

Key

Key objectives

Outcome measures

Current Baselines

Workflow

Me and my goals care plan template

Page Comparison

Versions Compared

Old Version 2

New Version Current

Key

Key objectives

Outcome measures

Current Baselines

Workflow

Me and my goals care plan template