ITS ALL ABOUT THE CONVERSATION

The conversation should help you to understand what the individual wants to achieve overall, and what they want to get our of your time together.

Its an opportunity to identify what really matters to them and what they think is a good outcome - this will vary from individual to individual.

Think holistically (beyond the gut) and not just medically. This could include mental well-being, fatigue, pain, extra intestinal manifestations and issues such as housing and employment.

Focus on staying well and living well. In understanding their motivations you will be able to navigate, together, how to move from goal setting to action.

Some questions and prompts you could use:

• What do you want to get out of our time together?
• How are things going for you at the moment?
• What do I need to know about you?
• What is important to you for your well-being? (e.g. family, job)
• What is important to you to keep you well? (e.g. exercising, limiting impact on work)
• How do you like to be supported? (e.g. written info)

PREPARATION, PREPARATION, PREPARATION.

Are there processes that you and your colleagues can put in place to make delivering more personalised care easier?

• Resources such as Crohn's & Colitis UK's Appointments Guide can support patients to reflect on what really matters most to them and plan conversations before appointments with helpful prompts and tips.
• Is patient information available and easily accessible? It's important for this to be both digital and written and in a variety of formats and literacy levels.
• Does your team have strategies in place to help you to identify and engage with patients with low levels of patient activation?
• Are you on the same page? Do your patients have the same understanding of care planning and their role in their care as you do? Consider including care planning as a learning topic in your local education and self-management programmes.

MAKE A PLAN TOGETHER

Having a personalised care and support plan will help you to deliver the individual's long term goals, taking into account their preferences and strengths.

When developing a solution talk through all possible options and support the person to understand the pros and cons, but don’t feel limited to just the obvious or sensible ones. It’s important that the solution is appropriate for them. Think about how you might support the person to prioritise their concerns and possible solutions.

Be clear about aspects of the plan the patient will act on and what you are responsible for. Your plan should communicate to the patient how you are all going to co-ordinate and work with other teams, such as primary care colleagues, to deliver a good outcome for your patient.

Use a care planning template to record the conversation and include it as part of the person’s health and/or social care records, owned by the person and shared, with explicit consent with the relevant members of the MDT.

REVIEW

Use contact with the individual to check how they are getting on:

• How do they feel?
• Do any changes need to be made to their plan?
• Is there anything that has been agreed that hasn’t happened?
• If things haven't progressed, why? Reflect together on whether the support/information given was the right kind.