The importance of care and support planning

Overview

Support Planning documents a series of conversations which you and other members of the multi disciplinary team (MDT)  will undertake with a service user/patient as part of an assessment process  to record information about the person’s health and wellbeing needs.

The person (or a family member) will work with you and the wider MDT to co-produce the plan,  which is personalised to the individual.  The plan will reflect

• The capturing and recording of discussions held, decisions reached and agreed outcomes in a way which makes sense to the person;
• A plan which is proportionate, flexible, co-ordinated and adaptable to the individual’s condition, situation, care and support needs.
• A description of the person, what matters to them and the necessary elements which make the plan achievable and effective.

You will be shown how a support plan is co-produced and completed as part of your training.  You may also be introduced to an on-line tool called Dialog or Dialog+ as part of your training.

The benefits of a collaborative approach are that you will discuss and identify what is important to the person (and their family); things they can do to live well and stay well; what support they need for self care and what good looks like; what action they may need to take in an emergency situation and support preparing for the future, based on choice and their preferences.

A care plan is owned by the patient/service user; it is recognised by all health and social care agencies who are involved in the provision of care, support and treatment to the individual; it is written in conjunction with the patient/service user and aids transition through the health and social care system by reducing the need for the individual to repeat their story and needs.

You may come across different models which explain the concept of care and support planning (such as the House of Care framework)  or the “whole-system” approach which also looks at the role providers of care/support play, the role of carers and how care is “commissioned” in ensuring that the plan is person-centred.

As a Care Co-Ordinator  you may be involved in the identification of patients/service users who would benefit from a detailed care and support plan to ensure that priority patient groups have the right support mechanisms in place for self-management, support, provision of advice etc.

Care and support planning may also be supported by  a “treatment plan” which may be developed in different health and social care settings for different conditions and purposes for example a treatment plan may be developed to support a person who is coming to the end of their life, a discharge plan, emergency health care plans or crisis care plans etc.

Why is this important

Research has show that people who are involved in the planning of how they wish to receive care, treatment and support are more likely to adopt healthier behaviours and rely less on emergency care.

A support/care plan is a guide and action plan of what support needs are required by the patient/service user.  Without it is hard to know what care will be provided and other important information about the service user/patient.

The practical support which family members and carers provide in the support planning process is important.  They can provide a different perspective on the individual’s health and care needs when these are being discussed and considered.  This may be particularly important if the service user/patient does not have capacity to make decisions.

Care and support planning can assist people with understanding their condition or disability better, or help them to be more confident and able to manage their own health and care, it also ensures that the patient/service user plays an equal role in the decision making.  An effective planning process will identify the key strengths of the person and build on these so that they feel supported.  Similarly it will help identify any trigger points or early warning signs which may alert professionals to a deterioration in the person’s health and wellbeing.

Skills Review

Having completed this sub-topic I will understand the importance of these skills.

• I am able to complete an effective care and support plan which is individualised and has been co-produced with the service user/patient.
• I am able to engage and encourage joint decision making and support the individual to set goals and review progress.
• I am able to identify ways to assist the individual monitor their wellbeing and understand when to take appropriate action (including seeking help in an emergency situation).