Based on the health information we hold some patients health conditions may mean that there is a possibility that they could need hospital care in the next year or so. The practice has been inviting some patients to consider receiving extra support or advice from our teams of practice and community based staff as part of our Care Plan Approach. The Primary Health and Social Care teams, which include your GP, nurses, other health professionals and social workers, are committed to enabling you to stay as well as possible and avoid having to go to hospital unnecessarily.

What is the Care Plan Approach?

The Care Plan Approach enables Health and Social Care team members to support you so that you can stay in your own home where at all possible. A Care Plan will be developed with you which will show:

• who your key worker is
• the way you are day to day
• what your needs are when you are less well
• how your needs will be met
• your overall wishes
• where you would like to be cared for

The care plan will be drawn up with you and kept in your home.

I am not ill at the moment so why do I need extra advice?
The Care Plan approach will make sure you are receiving the right care, support and/or treatment at the right time. We want to do this in good time, so that you stay as well as possible and avoid future problems.

How long will you be involved in the Care Plan approach?
This will be different for each person. Some people will need extra advice for 2-3 months, some will need longer. The decision about how long our help is required will be made between you, your GP and the other members of the Primary Health and Social Care teams involved in your care.

How will your Primary Health and Social Care Team members be kept up to date with your situation?
The Primary Health and Social Care team members will share the latest version of your Care Plan with each other.

The Care Plan will assist all Health and Social Care workers in and out of office hours who may need to visit you at any time.

How do the Primary Health and Social Care Teams work together?
The Primary Health and Social Care Team members meet regularly to discuss patients who have a care plan.

What happens next?

Over the coming days and weeks the Primary Health and Social Care team member(s) will introduce themselves and discuss your needs with you. They will provide you with the contact details of the health and social care professionals involved in your care and make referrals onto new services as required.

You will receive a copy of your Care Plan either in person or by post. Please keep the care plan in the green plastic wallet provided, with any other information that is given to you by your GP, Primary Health Care and Social Care teams.

Keep your Care Plan next to or on your fridge as this is the place all professionals will always look for information written about you and your care.

Your information

Any shared information will be held securely on the systems run by the organisations handling your care. This will be in accordance with the Data Protection legislation.

With your permission your plan may be shared with the following relevant care providers.

• Primary Health and Social Care Team members
• Out of Hours GPs – Frendoc/Brisdoc
• Ambulance Service
• Hospitals - if you are admitted
• South Gloucestershire Health and Social Care Single Point of Access
• Mental Health Community Teams – if appropriate

This is to ensure your Care Plan is available to be used by Health and Social Care Providers at all times.

Please let the practice know if you would prefer not to share this information as described above.

Contact Telephone Numbers

You will be given contact telephone numbers to use if you become unwell, or to pass messages to members of the team supporting you.

If you are unsure who or how to contact anyone involved in your care, then contact your GP surgery.