Care Plan Overview
By Connecting for Health | 2012
This article outlines the health context of care plans. It identifies different types of care plans mainly within the Long Term Conditions (LTC) care domain and talks about the importance of being able to share them across different care settings and between different health professionals.
What is a Care Plan?
There are no standardised or agreed definitions for what a “care plan” actually is, but for the purposes of this article, we will define a care plan in broad terms as a document that has the following attributes:
- It relates to a single individual
- It supports future care for an individual
- It aids decision making about future care
- It may also record decisions made about care
There are a number of things that a care plan is not:
- An electronic patient record (although the care plan is part of the overall electronic patient record for a patient)
- A record of all activities and encounters a patient has with services
- A personal health budget
- Detailed “measurements” (either manual or from a Telehealth device)
- eConsultation (although care planning activities may be delivered over an electronic channel in some cases)
- A care “pathway”
Many of the above could be considered “supporting information”, required to create and maintain a care plan, but they are not a plan in themselves.
Types of Care Plan
Whilst this article does not focus on the specific content of the care plans being shared, it is useful to understand the various different types of “care plans” that are being used to support patients with long term conditions. There are no standardised or agreed definitions for the types of care plans, so we will start with a break-down of the types of plans that are commonly identified as shown in figure 1.
In some cases, teams use combinations of these types of plans together, for example the “personalised care plan” may in some cases incorporate a “treatment plan”.
These broad categories are a generalisation, and all these kinds of plans will often be of use in other care settings also. It is important for the integrated team managing the patient, as well as the patients GP, to have a view of all plans relating to the patient.
Personalised Care Plan
Also known as Integrated Care Plan or LTC Care Plan.
The Personalised Care Plan is the primary focus for most long term conditions teams, as it is a key component underpinning the work done by integrated neighbourhood teams, as well as for informing the patient and supporting them in managing their condition.
A typical set of attributes of what a personalised care plan should be are:
- It is the output of a collaborative “care planning” process, which aims to maximise the patient’s capacity to self-care
- All patients with one or more long term conditions should have one
- There is only one per patient, and it is personalised and specific to that patient
- It shows the overall plan for the care of that patient – all specialties and all support needs
- It is not just about clinical interventions, but also covers both clinical and personal goals
- It should be structured around a minimum core set of information:
- “Problems” (e.g. Diabetes, COPD) – each with:
- “Needs” (e.g. Blood Glucose Management) – each with:
- “Goals” (e.g. Blood Glucose Normal) – these must be meaningful to the patient. These may be separated into “Clinical Goals” and “Personal Goals”.
- “Activities” (e.g. Review Medication, Refer to Dietician) – may be linked to Goals
- “Needs” (e.g. Blood Glucose Management) – each with:
- “Problems” (e.g. Diabetes, COPD) – each with:
- It should be created and updated in consultation with the patient
- The patient (or carer) should have access to it, and be able to understand it
- The patient should be able to add to and update aspects of the plan themselves
- There may be other more detailed care plans held in other systems (e.g. An acute care plan in a hospital), but the personalised care plan should give the overall summary view of activities for managing the patient‟s condition(s).
There are other types of care plan listed below, which are not in themselves part of the personalised care plan, but may inform that plan, and may indeed be “linked” or “signposted” from the personalised care plan.
In attempting to provide a complete holistic view of care for a patient, there is a danger that the plan ends up either unsuitable for the patient to use (i.e. it is too complicated), or unsuitable for staff (not detailed enough). Getting the right balance is important, and the ability to provide different “views” (or “filters”) of the care plan information targeted at different audiences is likely to be something that care plan systems need to consider to overcome this.
Also known as Nursing Plan, Acute Care Plan or Intervention Plan.
This is a clinically driven plan, covering:
- Prescribed procedure, therapy or medication for a certain condition
- May include goals and actions, but these are generally clinical activities only
Some aspects may be included in the personalised care plan if the patient will be carrying out treatments themselves.
Also known as Social Care Plan.
This is a plan created by social care teams, and is generally driven by the output of formal assessments as part of a common assessment framework. It is often linked to a personal budget that supports the individual’s support needs. In the longer term it is important that this information is also incorporated in some form into the personalised care plan to ensure that this provides an overall view of care and support for the patient.
Also known as Anticipatory Care Plan, Exacerbation Plan, Crisis Plan or Emergency Care Plan.
These often overlap or are combined with the treatment plan and/or the end of life care preferences, and are intended to help support the patient in managing potential future events relating to their condition(s). It may cover:
- What to do when the patients condition deteriorates, and may include instructions for emergency care professionals (e.g. paramedics).
- Symptoms to look out for, additional medication or actions to take to manage the exacerbation.
- Treatment advice for the patient. For example, for Asthma it may give advice on when to increase inhalers, and for Diabetes it may give individual guidance regarding changing insulin doses depending on blood sugar reading/meal types and activity planned.
- “Normal” values for patient readings (Pulse, Blood Pressure, etc).
- Contact details for carers, next of kin, and emergency clinical contacts.
In some cases the “emergency care” elements may be separated from the general patient advice around possible exacerbations.
There are some aspects of this kind of plan that may need to change rapidly if a patient starts to deteriorate, and it is important that unscheduled care services have up-to-date information to support any emergency situations.
End of Life Care Preferences
Also known as Advance Care Planning or Electronic Palliative Care Plan.
Captures details about a person’s preferences regarding their care at the end of their life.
An ISB standard exists which covers the core clinical content of end of life care plans. Wherever possible, any system capturing end of life care plans should do so in accordance with the core content outlined in this standard.
The core content detailed in the standard comprises information about:
- The person
- Those delivering care
- End of life care preferences and choices
- End of life care decisions
This plan may need to change rapidly if a patient starts to deteriorate, and it is important that unscheduled care services have up-to-date information to support any emergency situations.
More generally, “Advanced Care Planning” is a voluntary process of discussion and review to help an individual who has capacity to anticipate how their condition may affect them in the future and, if they wish, set on record choices or decisions relating to their care and treatment so that these can then be referred to by their carers (whether professional or family carers) in the event that they lose capacity to decide once their illness progresses.
Under the terms of the Mental Capacity Act 2005 formalised outcomes of advance care planning might include one or more of the following:
- Advance statements to inform subsequent best interests decisions;
- Advance decisions to refuse treatment which are legally binding if valid and applicable to the circumstances at hand;
- Appointment of Lasting Powers of Attorney (‘personal welfare’ and/or ‘property and affairs’).
Care settings and Teams
Integrated Neighbourhood Teams
The sharing of care plans is a key enabler for the creation of integrated neighbourhood teams. In many cases these teams already exist (or are being formed) and are having to rely on manual sharing of information. This is often achieved by physically coming together for a review meeting where the relevant information about the patients in their caseload is shared and reviewed. Whilst this works well, it does limit the amount of information that can be shared (i.e. it is only what the participants bring to the meeting), and the sharing is limited to the times when the group can come together.
The participants/roles that typically make up an integrated team include:
- GPs and Practice Nurses
- Community Matrons
- District Nurses
- Specialist Nurses
- Social Care Workers
- Hospice Staff
In some cases, this extends into other areas – although these wider participants are often only involved as and when required:
- Mental Health Teams
- Other Nursing and AHP teams
- 3rd Sector Teams
- Other supporting areas such as Housing, Employment, Benefits, etc.
The composition of the integrated teams will be driven by the needs of the local population, but should ideally include all the services required to provide for the care and support needs of patients.
Unscheduled and Emergency Care
Others who are likely to have a need to access care plans for a patient are unscheduled / emergency care providers – e.g.:
- Ambulance Services
- Out of Hours GP Services
This is especially pertinent for escalation plans and end of life care preferences, but having access to all the care plans for a patient is desirable in many cases to ensure the best information is available to support care.
There are some other specific technical considerations when non-NHS organisations (e.g. Local Authorities and 3rd Sector organisations) are involved in the sharing of care plan information. This is likely to be a growing need, as more types of provider organisation are engaged to provide care for patients. There are examples of social enterprises outside the NHS taking on the provision of services to NHS patients in competition with existing services in Acute trusts, and this is likely to grow over time.
Third sector organisations often provide services to support patient self-management activities, and there is a need to be able to share outcome information from these services which can feed back into care planning discussions, and to commissioners.
A key consideration for such organisations is the identifier used for patients. NHS numbers are used within NHS services to identify patients, but there are technical challenges in using the NHS number outside NHS organisations.
Care Plan Co-Ordination
The caseload of the integrated teams is usually driven by GPs and other clinicians identifying patients who they feel are at high risk. Increasingly, this is being supported by the use of risk data about the local population, usually gathered though the use of risk profiling tools. Where such tools do not exist, these teams may rely on referrals from other care settings.
An approach that has been used very successfully in some teams is to have a “key worker” or primary contact for each patient on the integrated team’s caseload. This provides a single point of contact for the patient, and can help act as an advocate for the patient and help them to understand the various services that are available to help them manage their condition.
Management of Shared Care Plans
If care plans are to be shared amongst members of the integrated team, and also with other care and support providers, it is important to agree the basic principles around who will create, read, update, and potentially “archive” plans. In many cases it is preferable for all parties in the integrated team to be able to create, read and update plans. In other care settings (e.g. unscheduled and emergency care), read-only access to care plans may be sufficient. This may differ for different types of care plan – for example, it may be useful for an out of hours GP to be able to update an escalation plan, but maybe not a personalised care plan. These basic principles should be agreed locally to match the responsibilities of the various teams involved in patient care.
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