Collaborative Care and Support Planning Guidance

The landscape of the NHS and primary care is changing; an ageing population, increasing multimorbidity and frailty, and an overburdened workforce means that primary care needs a more effective way of addressing the bio-psychosocial elements of health. It requires a shift towards prevention, self-care and integrated care.

Collaborative care and support planning (CCSP) offers a framework, which recommends a proactive holistic, flexible, and tailored approach to care, and recognises the individual as an expert in their own care. This toolkit provides a collection of relevant tools and information to assist members of the primary care team to implement the six-step model of collaborative care and support planning.

Step one: Context

1. Identifying the cohort of people to whom you are going to offer CCSP
2. Identifying individuals and generating a comprehensive database
3. Proactively inviting people for review
4. Developing robust/recall systems
5. Quality assurance of the process

Step One: Context [PDF]

Step two: Preparation

1. Local CCGs can play a pivotal role.
2. On a practice level, a pathway for CCSP needs to be developed.
3. Requires identification of an MDT  and training.
4. Patients and their carers also need to be informed an educated about CCSP.
5. Health navigators may help patients identify goals and signpost to resources.

Step Two: Preparation [PDF]

Step three: Conversation

1. CCSP should be a conversation directed by the patient, exploring their health and wellbeing.
2. This conversation does not have to take place with a GP.
3. Shared decision making and health coaching are key tools and skills that can be used.
4. Understanding a patient’s health literacy can also allow tailoring of discussions.

Step Three: Conversation [PDF]

Step four: Record

1. The care plan should be seen as an attempt to support people in taking greater ownership of their condition.
2. It is not legally binding although may include mandates such as ‘do not resuscitate’ or ‘power of attorney’.
3. Ideally, it should include a care plan articulating goals, a management plan (including social prescribing) and an escalation plan for the urgent care system.
4. Consent to share within the plan should be recorded.

Step Four: Record [PDF]

Step five: Making it happen

1. Surgeries can work together to by providing local intelligence and encouraging funders to commission services.
2. Local systems may develop a directory of services that will be available to the population offering a range of services.
3. This may in time be tied in with Personal Health Budgets (PHBs) and their promotion.

Step Five: Making it Happen [PDF]

Step six: Review

1. Care plans should be reviewed annually although patients with more complex needs may need more frequent reviews.
2. Ownership of the document should be given to the individual or a nominated person if the individual cannot take ownership.
3. Feedback from both patients should be obtained. This can be via surveys related to their experience of the service or those looking at the impact on their wellbeing.
4. More specific clinical outcomes can also be gathered.

Step Six: Review [PDF]

Background information and acknowledgements

This section contains further useful background information on CCSP. This includes links to documents that provide an overview of the CCSP process and national drivers for adopting the model.

This guidance was produced in collaboration with the Coalition for Collaborative Care (C4CC). The Coalition for Collaborative Care is a partnership of 50 national organisations and 2000+ members and followers aiming to achieve a better deal for people with long-term conditions.  The Coalition’s purpose is to bring people and organisations together and grow a movement for change around the three ‘C’s – better conversations between health professionals and the people they support, co-production with people, families and carers and building strong, health-creating communities. 

Background Information and Acknowledgements [PDF]

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