Care planning for long term conditions in primary care: indicators of embeddedness

Abstract

Rationale, aims and objectives: Healthcare systems are continuously challenged to develop new ways of working to meet the demands of an increasing prevalence of multi-morbid long term illness. Care planning has been proposed as one solution. This analysis used the Normalisation Process Theory as a framework to identify precursors of embeddedness of care planning in 10 primary care practices.

Methods: GPs, Nurses and Practice Managers from the selected practices took part in a series of collaborative learning workshops and a training programme. The data informing this article derive from 15 semi-structured interviews and from observational data collected during 4 collaborative meetings.

Results: A key step in the meetings was collaboratively to differentiate the care planning function from previous practice. Later interviews showed a clear movement towards the generation and implementation of pragmatic solutions. These included the adaptation of pre-existing tools, IT systems, call and re-call procedures and documentation and communication procedures in order to implement care planning for diverse patient needs. Implementing the care planning function entailed a renegotiation of roles between clinicians as well as with patients, the explicit inclusion of practice managers and a consideration of relationships with secondary care and other local services. Participants provided anecdotal evidence of the benefits of care planning and reported having received positive feedback from patients.

Conclusions: The learning collaborative enabled participants to shape care planning to fit their individual practice contexts, in terms of resources, structures and systems as well as in terms of the patient population. It emphasised the need for differentiation from prior practice, individual and communal specification and internalisation and fostered a sense of ownership.