As part of the patient’s annual health check, practices will be required to produce a health action plan. A health action plan identifies the patient’s health needs, what will happen about them (including what the patient needs to do), who will help and when this will be reviewed.
The focus of the health action plan is the key action points (whether for the patient, the practice, or other relevant parties involved in the patient’s care) and agreed with the patient and carer (where applicable) during the health check. It should also summarise what was discussed and any other relevant information (e.g. what is important to the patient, what their goals or outcomes are that they want to achieve).
Where the patient has a personalised advanced care plan in place, it is expected that this would also form part of the patient's health action plan.
It may include health promotion activity, monitoring e.g. weight, referrals to community health and acute services, pain management etc.
Other examples include recommendations for sight tests, dental checks, self management etc.
This can be created at the time of the health check using the section provided in the local electronic template in the GP clinical system. This needs to be printed and completed. The patient needs to be given a copy and the practice needs to ensure a copy is scanned into the electronic record. Alternatively the practice can use this health action plan template to create their own electronic version which can be completed on screen and printed off for the patient.
Is the health action plan understandable?
Practices will need to be mindful of the patient’s ability to read and/or understand the information contained in the health action plan. The practice will need to ensure that the health action plan is provided in the best format for the patient to maximise their understanding and involvement, this may mean a format most suitable for a carer or advocate supporting them to understand its content. The communication toolkit developed by Derbyshire’s specialist speech and language therapists will help you.
What other health action plans are available?
Some patients may bring with them their own health action plan, which you could update following your findings at the annual health check. This could be one that their service provider or carer helps them with. Many people in Derbyshire have a blue health file which is used as a health action plan. The advice that you give can be added to the health file using the health action plan template. The clinician needs to log this and record the actions in the clinical record.
Some young people may have an education, health and support plan which you can add information to. For young people the health action plan should consider the move from children’s health services into adult services. You may need to identify which services are currently covered by school or Paediatrics and how these will be met in adulthood. There may not be an automatic transfer and you may need to instigate referrals.
Practices may wish to provide the patient with a post-health check action plan patient letter, written in easy read format.
Sharing the health action plan
Where possible, and if the patient is mentally competent to provide it with their consent, the health action plan should be shared with other relevant professionals and carers who are involved in the care of the patient. Carers can be consulted but cannot consent or withhold consent on behalf of the adult that they care for (see mental capacity section).
Carers are particularly important in regard to the health of people with learning disabilities. We have produced a booklet for carers to help them to understand how to keep people with learning disabilities healthy. This can be downloaded for carers. Hard copies are in the packs given to the surgery.
The 12-month challenge (widget symbols) has been developed to help carers and people with learning disabilities consider a healthier lifestyle. The annual health check is the ideal opportunity for the clinician to discuss a healthy lifestyle and issue the challenge as part of the health action plan. Booklets have been delivered to the practices to give to patients. The 12-Month Challenge booklet is also available in photo symbols.
The Strategic Health Facilitators have provided each Derbyshire GP Practice with a folder containing easy read information, useful symbols and sources of information. Some web links are below which can help with supportive information regarding different health conditions, tests and procedures.
Care for people with diabetes and a learning disability
A collaborative team funded by The Health Foundation and the University of Leeds has created a set of evidence-informed, practical resources to improve care for people with diabetes and a learning disability.
Information can also be found below about living with a learning disability and diabetes. Guides supplied courtesy of Michelle Denyer, Lead Community Diabetes Specialist Nurse for Derbyshire Community Health Services NHS Foundation Trust.
Image courtesy of Widgit: