NHS Yorkshire and the Humber - Personalised Care Planning

The Long Term Conditions (LTCs) Programme at NHS Yorkshire and the Humber has been working to develop a suite of templates within TPP SystmOne that support Personalised Care Planning with patients living with LTCs. The aim of this work is to create something that supports and facilitates healthcare professionals to adopt the personalised care planning approach and to standardise best practice at a regional level.

The template suites are two-fold; at the first level there is a generic personalised care planning template developed to support and enable the emerging holistic approach to care of patients who could be living with one or more LTC. This generic template provides a link into the full list of standard LTC QOF templates as well as NHS Choices for access to Information Prescriptions.

To further support this, a set of specialised condition-specific templates have been created that sits alongside the QOF list. The first of this specialised set is the Diabetes (Adult) templates which were designed in 2009 with support from NHS Bradford and Airedale to meet the requirements of the Diabetes Year of Care Programme. Following demand from clinicians across the region, the Yorkshire and Humber Programme for IT Form Builders have gone on to create a wide range of templates. In collaboration with stakeholder groups, and following a robust process, the Form Builders are currently developing and testing templates to support Asthma (Paediatric and Adult), COPD, Diabetes (Paediatric), Epilepsy and Stroke. In addition to these they are also developing an area within the generic LTC templates to capture an Emergency Care Plan.

A guide on how to gain access to the templates can be found below:

doc icon LTC Template joining instructions v2 (1.1MB)