Care planning as a knowledge exchange platform: potentials, pitfalls, achievements

Background and context Care planning aims to realise the full potential health care practice and system redesign for partnership working with people with long-term conditions (LTCs). There is an urgent need to establish how to transfer the policy directive and underlying body of knowledge into everyday clinical practice in primary care for people with multiple LTCs. Approach to knowledge exchange Twelve GP practices have formed a learning collaborative, taking key lessons from the Diabetes Year of Care programme and exploring the practical implications of implementation with people with other or multiple LTCs. Clinical implementation and collaborative will happen concurrently, enabling a consistent and systematic harnessing of key experiential learning. Ultimately, the programme aims to establish key enablers to overcome the barriers and support wider implementation across the North East. Assessing the impact A formative evaluation is being undertaken, drawing on realist principles (Pawson and Tilley, 1997*), which pose that intervention mechanisms (M) are dependent on a number of contextual factors (C) to produce desirable outcomes (O). An increased understanding of the coupled C-M thus enables the manufacture of most successful interventions. In particular, practices and socio demographic contexts within which practitioners are implementing care planning are likely to differ drastically. Highlighting these contextual factors will generate understanding about why care planning may appear more successful, or easier to implement, in some practices. Outcomes will partly be assessed through a patient survey. Knowledge exchange will thus happen iteratively between practitioners, commissioners and evaluators. Lessons and messages The system redesign required for implementation of care planning in people with multiple LTCs poses a significant logistical and, particularly, cultural challenge. We anticipate our collaborative, iterative approach to be instrumental in addressing these. The formative evaluation will help highlighting the potentials and pitfalls of implementation processes, and will provide a platform for wider implementation.