Care planning

Fundamental to care planning is the principle of patient-centred care which places the person as the focus of any healthcare provision. The focus is on the needs, concerns, beliefs and goals of the person rather than the needs of the systems or professionals. The person feels understood, valued and involved in the management of their condition. People are empowered by learning skills and abilities to gain effective control over their lives versus responsibility resting with others. (Michie, Miles & Weinman, 2003)

Care planning is underpinned by shared decision making and communication skills that support behaviour change and improve health literacy. 

Key principles of personalised care planning

Personalised care planning is:

• A continuous process resulting in an overarching care plan that is regularly reviewed
• A holistic, systematic approach based on the person/whanau’s strengths, values and aspirations and puts their goals, choices and lifestyle wishes in the centre of the process
• A dynamic process of discussion, negotiation, decision-making and review that takes place between the person and the professional – who have an equal partnership
• Planned, proactive and anticipatory with regular follow-up and emergency planning for crisis episodes

The person should be encouraged to have an active role in their care, be provided with information or signposting to enable informed choices and supported to make their own decisions within a guidance of managed risk.

Assessment and care planning views the person ‘as a whole’ supporting them in all their needs and individual diverse roles, including family, parenting, relationships, housing, employment, leisure and education.

Information about support networks, including peer support, carers and family support groups are included.

Results in an overarching, single care plan that is owned by the person but can be accessed by those providing direct care.

What is included in a care plan?

A care plan typically includes:

• Mutually agreed list of problems
• Person defined goals
• Medical management, including medications
• Prioritised action plan/interventions/steps/tasks - based on SM needs of person and their carer/support network
• Crisis or contingency planning with written information re. early warning signs/red flags & action to take
• Who is responsible for what with sharing of responsibility
• Key actions and tasks in person’s preferred language
• Time and method for review & follow up

Benefits of care planning

The benefits of care planning extend from improving communication and coordination through to satisfaction, improving wellbeing and acute demand. 

Who should have a care plan?

Anyone with a long-term condition can benefit from having a care plan.

People at low to moderate risk of developing complications of their condition should be encouraged and supported to self-manage their condition and can benefit from having a clear and simple plan that facilitates lifestyle change and medical concordance.

Approximately 20% of the population utilise 80% of the resources and this group would benefit from someone sitting down and spending the time to create a more comprehensive care plan. This can facilitate the shift from a more typical, reactive approach (dealing with acute problems) to one that is more planned and proactive. By planning ahead for the next 12 months, a number of common complications can be anticipated and planned for. 

For example, a person with COPD is at risk of developing acute exacerbations. If they have a care plan with clear information about what to do when they get sick (often called an acute plan or COPD Action Plan, or Blue Card) then the person and their family know what to do sooner, when to take their reliever medicine and can sometimes avoid getting worse and ending up in hospital. 

Care planning with electronic care planning tools

Electronic tools are being increasingly used to document care plans. These tools can significantly improve the coordination and sharing of information between the patient and their healthcare team. These tools are usually part of larger patient information system and include a patient portal.

• For more information about patient portals 
• ARI case study

Other care planning tools

A range of paper and computer-based care plans are available.

Within both community and specialist services, one systematic approach for care planning is the Flinders Programme. This provides a structured, holistic patient-centred approach to care planning that fits well with the principles outlined earlier.

Health Navigator has developed a set of tools designed to support people and their healthcare teams develop self-management plans.

The tools are:

1. Te Kete Haerenga – Your journey to wellbeing kete. Your toolkit for living well with an ongoing health condition
2. Te Kete Haerenga – Wellness toolkit. A shorter version that focuses on your plan for living well with an ongoing health condition.

Both of these resources can be used to support the development of a care plan. 

• For more information and examples of care plans and acute action plans.

Video

This 5-minute video sets out the four key stages in care and support planning: preparing for a consultation; discussing what people feel will help them stay well and what care and support they might need; creating a care and support plan that is easy for people to understand and use; and reviewing what has worked well, what hasn't worked well and what might need to change.

It shows the process in action with Lynne Craven and her care and support planning partner, Dr Alf Collins.

(Eye to Eye TV, UK, 2014)