Navigation

Care planning

Quality statement

People with diabetes participate in annual care planning which leads to documented agreed goals and an action plan.

Quality measure

Structure

Evidence of local arrangements and provision of resources to ensure that people with diabetes participate in annual care planning which leads to documented agreed goals and an action plan.

Process

a) Proportion of people with diabetes who are offered annual care planning including documenting and agreeing goals and an action plan.

Numerator - the number of people in the denominator offered annual care planning including documenting and agreeing goals and an action plan.

Denominator - the number of people with diabetes.

b) Proportion of people with diabetes who participate in annual care planning including documenting and agreeing goals and an action plan in the past 12 months.

Numerator - the number of people in the denominator participating in annual care planning including documenting and agreeing goals and an action plan in the past 12 months.

Denominator - the number of people with diabetes.

Outcome

Patient satisfaction with diabetes care using validated patient survey criteria.

Description of what the quality statement means for each audience

Service providers ensure people with diabetes participate in annual care planning with documented agreed goals and an action plan, and to support this, provide training for healthcare professionals.

Healthcare professionals ensure they are competent to support people with diabetes to participate in their care and enable them to agree on specific achievable goals and an action plan in annual care planning.

Commissioners ensure services are commissioned that provide training for healthcare professionals and encourage people with diabetes to participate in their own care.

People with diabetes are involved in annual planning for their own care, which includes agreeing on the best way to manage their diabetes and setting personal goals.

Source clinical guideline references

Adapted from Joint Department of Health and Diabetes UK Care Planning Working Group (2006) Care Planning in Diabetes.

Data source

Structure

Local data collection.

Process

a) and b) Local data collection.

Outcome

Local data collection.

Definitions

Adapted from Joint Department of Health and Diabetes UK Care Planning Working Group (2006) section 3 Care Planning in Diabetes.

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.

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
  • Expert Patients Programme.
  • agreeing goals for HbA1c
  • agreeing plans for managing diabetes
  • discussing goals
  • follow-up support by telephone.

A guide to implementing care planning in diabetes is available from Diabetes UK, NHS National Diabetes Support Team, Department of Health and Health Foundation (2008) Year of Care - Getting to grips with the Year of Care: a practical guide.

Equality and diversity considerations

All information about treatment and care, including care planning, should take into account age and social factors, language, physical, sensory or learning difficulties, and should be ethnically and culturally appropriate. It should also be accessible to people who do not speak or read English. If needed, people with diabetes should have access to an interpreter or advocate.

This page was last updated: 04 April 2011

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.