Personalized care and support planning – easier said than done.

Gill Wilson – lecturer in nursing on the University of Hull

Health policy has promoted the concept of personalized care and support planning as a strategy to deliver person-centred take care of individuals with long-term conditions (LTC) (Department of Health (DH), 2006; DH, 2008; Coulter et al., 2015). It is a collaborative approach that goals to discover what is very important to patients and align their preferences for health care through shared decision-making. This process is cyclical and involves setting goals, developing an motion plan, and monitoring progress to be certain that services meet individual patient needs (Edwards et al., 2017).

It is very important to tell apart between the ‘care planning’ activity described above and the output of the ‘care plan’ (a written or electronic record documenting the care plan). The care plan ought to be an energetic document, accessible to the patient and other professionals involved of their care, that ought to be referred to at each encounter and assessed over time (Burt et al., 2014; Edwards et al., 2017).

Most nurses are accustomed to care planning, however the concept of long-term care management is different from traditional, normally reactionary nursing care planning. Personalized care and support planning requires skills in shared decision-making, behavior change, coaching, goal setting and motion planning. Nurses and other healthcare staff involved on this process need training to develop these skills, which might be difficult to utilize in a busy healthcare environment. For this reason, health education in England has been called upon to work with healthcare skilled regulators to be certain that key elements of person-centred care, including personalized care and support planning, are included in curricula (Coulter et al., 2013).

There are several useful guides available, including those from NHS England, which might help health and social care professionals with their care planning process Personalized care and support planning guideAND A customized care and support planning tool by the Shared Care Coalition and the Royal College of General Practitioners Toolkit for planning shared care and support.

Primary care teams have the responsibility to supply personalized care and support planning. To implement it effectively and meet the needs of individuals living with long-term care, a major cultural change in the way in which health care is delivered is vital. Built on revolutionary ideas Year of Care project and the influential Chronic Care Model (Wagner et al., 1996), the Care Home model was adopted by NHS England. Although primarily focused on primary care, it relies on a holistic approach. The hallmark of this model is that the patient is placed at the middle and care is coordinated through personalized care and support planning. Another key feature of the model is the interdependence of the 4 structural elements: the 2 partitions, the muse and the roof, because without this infrastructure, coordinated patient-centered care is not going to be possible.

Source: NHS England https://www.england.nhs.uk/ourwork/ltc-op-eolc/ltc-eolc/house-of-care/

The implementation of personalized care and support plans for people in long-term care is slow. In 2008, Mr. Darzy committed that everybody in England with at the very least one LTC ought to be offered a personalised care plan. This has been further confirmed by the federal government mandate for NHS England that by 2015 “everyone with a chronic disease, including those with mental health problems, will be offered a personalized care plan reflecting their preferences and agreed decisions.” Given that nearly 30% of the population in England has at the very least one long-term care, providing care plans for 15 million people by 2015 was an ambitious task.

Nearly ten years after Lord Darzi’s oath in 2017 Patient survey normally practice reported that only 3% of individuals in long-term care were aware that that they had a written personalized care and support plan. Similar findings were reported in a previous study examining the implementation of care planning in England. Many patients didn’t know what the term “care planning” meant, and only 12% of patients were aware of getting a written care plan. However, 84% of patients reported having had a care planning conversation, although these conversations often lacked vital elements of goal setting and motion planning (Burt et al., 2012; Newbould et al., 2012).

The study by Kennedy et al. (2014) provided some insight into why practices supporting self-management, corresponding to personalized care and support planning, have been slow to be implemented. Staff felt they were already providing effective care and planning for personalized care and support didn’t fit with their existing biomedical priorities. Furthermore, some staff downplayed the importance of offering self-management support to individuals with long-term care and didn’t feel it was their role.

Until recently, empirical evidence supporting personalized care and support planning was limited, which can explain clinicians’ reluctance to implement these recommendations. However, a recent Cochrane review found that personalized care and support planning resulted in small but positive improvements in points of physical and mental health and will support individuals with long-term care in self-care practices and increase levels of self-efficacy (Coulter et al., 2015).

Implementing personalized care planning and support for adults with long-term health care is less complicated said than done. This process is complex and difficult for each patients and healthcare professionals and requires a fundamental shift from reactive care to proactive care planning. One size actually doesn’t fit all on the subject of long-term care management; nevertheless, evidence suggests that personalized care and support planning play a key role in a healthcare skilled’s arsenal to support person-centred care.

Bibliography

Burt, J., Rick, J., Blakeman, T., Protheroe, J., Roland, M. & Bower, P. (2014) Care plans and care planning in long-term settings: a conceptual model. Research and development of primary health care15(4), 342-354.

Burt, J., Roland, M., Paddison, C., Reeves, D., Campbell, J., Abel, G. and Bower, P. (2012) Prevalence and advantages of care plans and care planning for individuals with long run conditions in England. Journal of Health Services Research & Policy17 Supplement 1, 64-71.

Coulter, A., Entwistle, V.A., Eccles, A., Ryan, S., Shepperd, S., Perera, R., Coulter, A., Entwistle, V.A., Eccles, A., Ryan, S., Shepperd, S. and Perera, R. (2015) Personalized care planning for adults with chronic or long-term conditions. Cochrane Database of Systematic Reviews(3), N.PAG-N.PAG.

Coulter, A., Roberts, S. and Dixon, A. (2013) Providing higher services for individuals with long-term conditions: constructing a care home. London: The Royal Trust.

Department of Health (2006) Our health, our care, our opinion: a brand new direction for social services. London: Office, TS

Department of Health (2008) High quality take care of all: final report of the subsequent stage of the NHS review. London: Stationary Office,.

Edwards, ST, Dorr, DA and Landon, BE (2017) Can personalized care planning improve primary care? JAMA: Journal of the American Medical Association318(1), 25-26.

Kennedy, A., Rogers, A., Chew-Graham, C., Blakeman, T., Bowen, R., Gardner, C., Lee, V., Morris, R. and Protheroe, J. (2014) Implementation self-management support approach (WISE) across the health system: a process evaluation explaining what worked and what didn’t for organizations, clinicians and patients. Implementation science9(1), 129.

Newbould, J., Burt, J., Bower, P., Blakeman, T., Kennedy, A., Rogers, A. and Roland, M. (2012) Experiences of care planning in England: interviews with patients with long-term conditions . BMC Family Practice13(71).

Wagner, E.H., Austin, BT and Von Korff, M. (1996) Organizing take care of patients with chronic diseases. Milbank Quarterly74(4), 511-544.

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