Are you using Care Plans the right way?

Gaurav

Care-plan   Progress-notes   Care-notes   Shift-notes

Organised and digital care plans for aged care and disability services - ShiftCare

What is a care plan?

A care plan is a written record of the agreed care and treatment for an individual. It ensures that clients are looked after in accordance with their particular, individual requirements.

A care plan describes:

  • The needs of a participant
  • their views, preferences and choices
  • the resources available actions that a care team can carry out in order to meet their needs;
  • including emergency and risk-mitigation measures.

Care plans are also often referred to as ‘support plans’.

Why are care plans important?

  • A care plan is a legal document. Care plans are required by NDIS (for disability care) and the Australian Department of Health (for aged care).
  • Care plans guide all those who care for any given individual - including new carers, and anyone who may be filling in for a regular carer. With reference to a support plan, everyone who looks after a participant can be well informed and offer the best possible quality of care.
  • Care plans outline emergency procedures, as well as day-to-day plans. All staff working with a client read the client’s care plan before commencing, and will be prepared for challenging situations before they arise.
  • Care plans manage and thereby minimise risks for all stakeholders, including carers themselves, other care home residents, and members of the public

What should be included in a care plan?

The following is a list of information to include in a care plan:

  • Demographic information (e.g. age, gender)
  • Medical information
  • Personal routines
  • Participant’s interests and ideas for activities
  • All the participant’s needs, as identified in their needs assessment
  • Advice and information about what can be done to meet or reduce the participant’s needs.
  • Advice and information about what can be done to prevent or delay the development of additional future needs.
  • A risk assessment
  • Behaviour Management details.
  • Details of emergency procedures
  • A record of when the plan has been created, reviewed, updated and modified

Who should be involved in preparing and reviewing care plans?

You can easily upload updated care plans to a client’s profile if you use a digital care management platform, such as ShiftCare, and set a review date. This will send you a reminder that the care plan is due for a review. 

Notably, the participant themselves should be involved. According to the principle of ‘person-centred care planning’, care plans should be tailored to the service user, and meet their needs and preferences. This means that care plans should always be put together and agreed with the participant, throughout planning and reviews.

In addition, the following parties may participate in creating and reviewing a care plan:

  • The person responsible for the participant (if applicable)
  • Assessment organisations
  • Any carer that the participant has
  • Any other person the participant has asked to be involved
  • Representatives of care organisations (e.g. a care home or care provider)

Note that all carers and support workers are required to read and sign off the care plan, before their first shift with any given participant, to evidence that carer has read the file.

Person-centred care planning

One function of a care plan is to establish clear mutual expectations with service users and carers. To create a care plan, it is therefore necessary to gather the views of all concerned: the participant, their family, carers and professionals. 

However, the most important ingredients in a good care plan are the participant’s own views. Here’s a list of questions that can help uncover a participant’s needs:

  • What’s important to you?
  • What do you want and hope to do, and what is currently stopping you?
  • What is working well?
  • Who supports you?
  • What would you like to change?
  • How would you like your support to be?
  • What do you want to do next?

You may also take the ‘Wellness Recovery Action Planning’ approach, to identify care needs: 

  • What is the issue?
  • What makes it better?
  • What makes it worse?
  • Who or what can help?
  • What I (or we) plan to do:

The care planning cycle

Care planning is not a one-time event. There has to be an on-going process of reviewing, updating and modifying care plans, in line with participants’ changing needs and goals. Here is a step-by-step summary of how to manage the care planning cycle.

  1. Write a care plan
    • In collaboration between the relevant parties, draw up an individually tailored support plan. 
    • Seek adequate information in order to create a plan that reflects the individual’s strengths, goals, requirements and preferences.
    • Decide on support procedures; take time to explore choices, what’s most important, and the potential implications of different choices. 
    • Set goals to achieve outcomes, with timelines and specific deadlines. 
    • Include a clear list of actions, and who will be responsible for them.
    • Also include a risk assessment, in order to make care as safe as possible for all involved. This can take the form of a simple table outlining risks, their potential severity, actions that will reduce the risks, and procedures in case the risks arise.
    • Decide and state a date when the care plan will next be reviewed.
  2. Carry out reviews
    • Periodic Reviews
      • Risk assessments need to be reviewed from time to time, by both caregivers and participants. Changes and improvements to risk management strategies in care plans can be made at any time.
    • Annual Reviews
      • It is legally required that care plans be reviewed at least once every twelve months. Annual care plan reviews offer scheduled opportunities to assess progress and make changes according to participants’ changing circumstances and needs. 
      • (Note that it may be appropriate to review care plans more frequently, depending on the risks to any particular participant, and their individual wishes.)
    • Care plan review, or new assessment?
      • Depending on the circumstances, it may be more appropriate to carry out a care plan review or an entirely new assessment. The Australian government’s My Aged Care website offers guidance on how to decide whether a new care plan assessment or a care plan review is needed.
      • Note that support plan reviews can be carried out in person or over the phone. Results of all reviews are recorded on the client record.
  3. Respond to reviews by updating care plans
    • It’s important to make sure that information gathered and conclusions reached in the care plan review process are reflected by updating the client’s care plan. For example, it may be appropriate to adjust goals, add additional strategic options, or replace some strategies altogether. 
  4. Communicate changes to stakeholders
    • With the consent of the participant, communicate the new or updated care plan to all relevant stakeholders, including primary caregivers, family members, and other providers and agencies. A care management app, such as ShiftCare, can allow you to share care plans with chosen stakeholders at the click of a button. You can also assign document expiry dates, to indicate when the next reviews are due.

Conclusion

Care planning can and should be a satisfying and rewarding process for all parties involved.