Campaspe PCP

Getting started with Care Planning

Campaspe Primary Care Partnership

Objectives

To demystify Care PlanningTo increase understanding of care

planning and where it fits in practiceTo introduce the types of care plans To define the role of a key worker or

care coordinator

ContextService Coordination

Statewide approachPlaces consumers at the centre of

service delivery4 operational elements of SC are

Initial Contact; Initial Needs Identification; Assessment and Care Planning

Care Planning key work area of the Service Coordination Steering Committee and PCP Strategic Plan

Operational elements of Service Coordination

Resources

Victorian Service Coordination Practice Manual – 2009 (update due in July 2012)

Good Practice Guide 2009Continuous Improvement FrameworkService Coordination Tool Templates -

2009 user guideLocal Key Worker Roles &

Responsibilities document

Websites

www.campaspepcp.com.au

www.health.vic.gov.au/pcps/coordination

What is Care Planning?

Dynamic processInvolves negotiation, decision

making and goal settingRelies on good communication

between consumer, service providers and GPs

Care Planning ObjectivesPlanned, evidence based and person centredActively engage consumers in planningConsider social, emotional and health issuesBased on needs goals and actionsIncludes education and self management

interventionsMonitor and review progressUnderpinned by good communicationMeets legislative requirements

Benefits of Care PlanningAssist consumers to set goalsEncourages consumer involvement and

self-managementManages and monitors long term careProvides a checklistDocuments information e.g. action plansEncourages team approachesIs proactive rather than reactiveIncrease consumer awareness of services

Person-Centred Practice Principles

Partnership approachHolisticOpen communicationRespect and privacyInclusive of family and carersSupports self-management and

responsibilityParticipation in decision makingSupports autonomy

Types of Care Plans

Service SpecificIntra-agencyInter-agency

Service Specific Care Plan

This is a care plan developed by a single service

The consumer has one or more issues that can be managed with support of a single program area

• District Nursing treatment plan• Physiotherapy treatment plan• GP Asthma management plan

Intra-agency care plan

Require multiple services from a single organisation

Individual service specific care plansOverarching intra agency care planRequires key worker; eg.

Diabetes Services care plan HACC services plan

Inter-agency Care Plan

Consumer has range of chronic, complex &/or multiple issues

Involves separate agencies3 or more ongoing service providersKey worker

Complex care planCAPS case management care planGP team care arrangementsTransitional care plan

Elements of a Care Plan

1. Date2. Participants3. Consumer stated issues4. Consumer stated goals5. Agreed actions & service responsible6. Timeframes7. Review dates8. Consumer acknowledgement9. Actual review date

SCTT Care Coordination Plan

Issues to consider

Consumer stated or agreed issues

Do all consumers need all the care plans

Who is the key worker

Role of the Key Worker

Engagement and empowermentConsolidate informationService system knowledgeDocumentation of plan and

monitoringCommunication and liaisonFacilitating case conferencingProvision of feedback

Local documentation – Support guideCampaspe Care Planning Key

Worker Roles and Responsibilities document provides info on;o What is a care plan &

definitions o What is a key workero Steps in developing a CPo Roles and responsibilities

of the key workero References to tools/forms

to use

Goal Setting

Linked to problem/issueWritten in positiveWritten in the consumers wordsSMARTCan be maintenance goalsShould not be interventions

Setting Goals and Action PlanningSomething the consumer wants to

doAchievableAction specificAnswer what, how much, when, how

often?Confidence level 7 or more

Goal setting – practice example

Overall aim to lose weight.Goal

Specific- aim to help lose weight by increasing the amount of walking

Measurable- walk for 30 minutesAchievable- confident that could manage to

walk for that longRealistic- need to take the dog for a walk so

will be the motivation I need. Timely- will walk 3 times per week in the

afternoon

Conclusion

Care planning is part of service coordination

Each service will have specific involvement with care planning

Know what your role is?Be familiar with the documentation

Final point

It may seem time consuming but the aim of service coordination is to ensure the consumer receives the right help at the right timeby the right person

BE CONFIDENT IN YOUR ROLE IN THE CONSUMERS JOURNEY