Care planning for healthcare providers

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. 

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.

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

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

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. 

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

Working with people to identify something they want to do is one of the simplest, yet most effective techniques we can use to improve communication and behaviour change. A systematic review on improving diet, published by the Agency for Healthcare Research and Quality in 2002, included goal setting in a list of a few intervention components shown to be associated with improved behavioural outcomes. 

A goal-oriented approach to making healthcare decisions, assessing outcomes, and measuring success has several advantages:

• It frames the discussion in terms of what the person wants to do rather than what might be generally accepted as what they should do.
• It simplifies decision making for people with multiple conditions by focussing on outcomes that span conditions and aligning treatments towards common goals
• Goal oriented plans enable people and their healthcare team, to discuss which health problems are important to them and decide on priorities in the context of how they can achieve what is important to them.
• When priorities are known, people can collaborate with their healthcare team to determine steps to be taken towards achieving their goals and how progress can be monitored.

Goal setting is most successful if it includes follow-up, problem-solving, and adjusting activities if goals are not being achieved.

If the patient's goal seems clinically useless, go with it anyway. Starting where the patient is at is more likely to ensure continued success then forcing them to start somewhere else. (Mike Hindmarsh)

Action Plans to Support Behaviour Change

Action plans are detailed descriptions of the actions a person will take towards making a lifestyle or other behaviour change. The behaviour change is linked to the achievement of a goal.

1. Ask: “Is there something you would like to work on to help you achieve your goal?”
2. Guide development of the plan by asking
   1. What do you want to do?
   2. When will you do it?
   3. How often?

1. Gauge the level of importance and score on a scale of 1 to 10. If rated less than 7, adjust goal to something that is more important to the patient/client.
2. Assess Confidence. Again, score from 1 to 10 and adjust the goal to something that is 7 or more. A score of 6 or less suggests the goal is too hard. Likewise, if someone scores 10, then this goal is very easy for them and you could check if they wish to make it a little more challenging.  
3. Arrange short-term follow-up. A phone call, email, or text within one or two weeks of setting a new significant goal and change can make a significant difference to the likeliness of achieving it. Help the person problem solve if they are facing barriers or struggling to achieve their goal and action plan.
4. Document goal and actions/tasks in patient/client’s notes and be sure to ask about it at the next visit.

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(external link). This provides a structured, holistic patient-centred approach to care planning that fits well with the principles outlined earlier.

Healthify 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.

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)

• Collaborative care and support planning: a video introduction(external link) Royal College of General Practitioners 
• Personalised care planning(external link) Healthcare Education England 

• Year of Care: care planning in long-term conditions(external link) Diabetes UK