Working in Partnership - Saint Michael's Hospice

Personalised Care and Support Planning is a series of facilitated conversations in which the person, or those who know them well, actively participates to explore the management of their health and well-being within the context of their whole life and family situation. This process recognises the person’s skills and strengths, as well as their experiences and the things that matter the most to them. It addresses the things that aren’t working in the person’s life and identifies outcomes and actions to resolve these.

Personalised Care and Support Planning is key for people receiving health and social care services. It is an essential tool to integrate the person’s experience of all the services they access so they have one joined-up plan that covers their health and wellbeing needs.

People using a service have care or treatment that is personalised specifically for them. Providers must work in partnership with the person, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves.”

People might also use terms such as patient-centred, family-centred, user-centred, individualised or personalised, but they all mean the same thing. A care plan is simply a record of the outcomes of a care planning discussion between an individual and their health or social care professional.

Professional may already be working with certain plans that schedule treatments or medication, but a truly personalised care plan should include other information such as SMART goals, preferences and personal information. The most important aspect of a care plan is the initial discussion, as this will help to build the complete picture.

There is no national template for care plans, because a care plan should be a fluid document that is adapted to every individual. However, there are key domains to care planning that can be considered which may help local organisations and staff in developing local care plans.

Every care plan should include:

Personal details
A discussion around health and well being goals and aspirations
A discussion about information needs
A discussion about self care and support for self care
Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes
Any actions agreed
A review date

The Health Foundation has identified a framework that comprises four principles of person-centred care:

affording people dignity, compassion and respect
offering coordinated care, support or treatment
offering personalised care, support or treatment
supporting people to recognise and develop their own strengths and abilities to enable them to live an independent and fulfilling life.

It’s perfectly acceptable to use a care planning template for every person that is cared for, as long as they are used as a starting point, and not a complete document. Using a pre-existing care plan template helps to save time and can help make sure nothing is forgotten. But, in order to make sure they’re person centred, they need to focus on the goals and priorities of each person, with outcomes to match.

In each category, professionals will ask a number of questions about the individuals care recipient’s level of independence so that they can create a person centred care plan which fully understands their needs. Also recording any risks that may have been observed in order to decide whether further assessments are needed.

From there, adding tasks which will help the client achieve those outcomes and notes to each one, which make them person centred, and reviewing in real time when they’ve been completed.

Focus on what the person can do (rather than what they can’t)

When planning for home care, professionals need to specify whether or not a person can physically do something, so teams can assist appropriately. But in order to make a care plan person centred, speaking with the individual to gauge what they can do, and what they would like to do. Whilst it may be clear that they cannot walk unaided, they may get great satisfaction from choosing how they dress, or the activities they enjoy. By focusing on their strengths, this can build a care plan that helps to support their goals.

Keep everyone involved

Person centred care planning means making sure that everyone has a say - and treating everyone involved in the care of a person as an extended team member. Treat the people who use the services with empathy and respect; ask them about their wishes, their likes and dislikes and factors that will influence the care you provide. Agree on mutual expectations and be sure to review these frequently, involving all parties in any decisions.

You should also ensure that wherever possible respecting the privacy of those being cared for. If the use of paper care plans, kept in a person’s home, this means some potentially private information is available to any visitors to their home. Speak to the individual and ask them what they’re happy to share.

Ask for feedback (and action it)

Asking for feedback can seem like opening a can of worms. With so many people involved in a single person’s care, there will be many opinions that need to be respected. But, if a person-centred approach to care planning has been created from the start, this step should be relatively pain-free.

If feedback received has highlighted improvements or requests, be sure to communicate what will be done to action it. The easiest way to gather feedback is through a survey.

Professional should be in regular contact with the people being cared for, to offer them the opportunity to direct and discuss their care. This is a way to find out what’s working for them, what they’d like more of and how they can be supported. This helps to maintain a person-centred approach and ensures they are always in control of their care.

Strive for continuity of care

It’s not always possible to assign a care team to the same people all the time. But, wherever possible you should strive to ensure the person is supported by the same home care worker(s) so they can become familiar with them.

Professionals should also be actively trying to ‘match’ team members to the people cared for, taking into account: the person's care and support needs, and the care workers' skills, and if possible and appropriate, both parties' interests and preferences.

The key takeaway:

It’s important to remember that although person centred care planning can stem from a number of activities, it needs to be integrated into everything done within a setting. The idea of person centred care planning is underpinned by the philosophy of doing things ‘with’ people, rather than ‘to’ them. Being flexible to meet people’s needs and work with people and their families to find the best way to provide their care.