What is a Care Plan?

What is a care plan, this is me and advance care plan?

Care plans are an important and indispensable element of care provision, but what is a care plan exactly? Find out about best practices for writing care plans and learn about advance care plans and ‘This is Me’.

A care plan is a document that outlines the support and services that an individual will receive in order to meet their needs and achieve their goals. Care plans are commonly used in health and social care settings, and are used to coordinate and plan the care that individuals receive from a range of providers and services.

A care plan typically includes information about:

  1. The individual’s needs: This may include information about their physical, emotional, and social needs, as well as any medical conditions or disabilities that they have.
  2. The individual’s goals: The care plan should outline the individual’s goals for their care, such as maintaining their independence, improving their health, or staying in their own home.
  3. The services and support that the individual will receive: This may include information about the care and support that the individual will receive from different providers and services, such as health and social care services, and community-based services.
  4. How the individual’s progress will be monitored: The care plan should outline how the individual’s progress will be monitored, and how the care and support that they receive will be reviewed and adjusted if necessary.
  5. The individual’s preferences and choices: The care plan should take into account the individual’s preferences and choices, and should reflect their views and opinions about their care.

Care plans are an important part of ensuring that individuals receive the care and support that they need, and that their care is tailored to meet their specific needs and goals. Care plans are also an important tool for communicating information about the individual’s care between different providers and services, and for coordinating the delivery of care.

What is a Person Centred Care Plan?

Person-centred care planning is an approach to care and support that focuses on the individual’s needs, preferences, and goals, rather than solely on their medical or care needs. It is a coordinated process that involves the individual, their family and carers, and healthcare and social care professionals, and seeks to empower the individual to be as independent as possible.

Person-centred care planning involves:

  1. Understanding the individual: Gathering information about the individual’s background, personal history, and current needs, preferences, and goals, to ensure that their care is tailored to meet their specific needs.
  2. Involving the individual in the planning process: Ensuring that the individual is involved in all aspects of their care, including the planning and delivery of their care, and that their views and preferences are taken into account.
  3. Developing a care plan: Creating a care plan that outlines how the individual’s needs, preferences, and goals will be met, including what support and services they will receive, and how they will be involved in their care.
  4. Monitoring and reviewing the care plan: Regularly reviewing and updating the care plan to ensure that it continues to reflect the individual’s changing needs, preferences, and goals, and that they are receiving the care and support that they need.

Person-centred care planning is designed to promote independence, choice, and control for the individual, and to ensure that care is delivered in a way that is responsive to the individual’s needs, preferences, and goals. It is an important tool for ensuring that individuals receive high-quality, person-centred care, and for promoting positive outcomes for individuals, their families, and carers.

If you want to learn more about person-centred care, you can take our Care Certificate course here.

Care Plans & the First Person

It is considered good practice to write care plans in the first person, as this helps to personalise the plan and make it more individualised to the person receiving care. Writing the plan in the first person can also help to ensure that the person’s voice and preferences are reflected in the plan, and that their needs and goals are being met.
For example, instead of writing “The patient requires assistance with bathing,” the care plan could be written as “I would like help with bathing.” This approach can help to empower the person receiving care and make them feel more involved in their own care.
It is important to note that the care plan should be a collaborative effort between the person receiving care, their family or carers, and their healthcare providers, and should be reviewed and updated regularly to reflect any changes in the person’s needs, preferences, or goals.

What is an Advance Care Plan?

An advance care plan is a document that outlines an individual’s preferences, values, and goals for their future medical treatment and care. It is created in advance of a time when the individual may no longer be able to make decisions for themselves, such as in the event of serious illness or injury.

An advance care plan typically includes the following information:

  1. Treatment preferences: This section outlines the individual’s preferences for medical treatment, including any treatments they wish to receive or avoid, and their preferred location of care (e.g. at home, in hospital, or in a care home).
  2. End-of-life wishes: This section describes the individual’s wishes for end-of-life care, including any pain management preferences and preferred location of death.
  3. Personal values and beliefs: This section outlines the individual’s personal values and beliefs, including any religious or spiritual beliefs that may influence their care preferences.
  4. Designated decision maker: This section identifies the individual’s designated decision maker, who will make decisions on their behalf if they are unable to do so.
  5. Advance directive: This section may include an advance directive, which is a legal document that gives specific instructions for medical treatment, or a living will, which is a non-binding document that outlines an individual’s treatment preferences.

Advance care planning is an important aspect of healthcare and is encouraged by many healthcare organisations. It helps ensure that individuals receive care that is in line with their preferences, values, and goals, even if they are unable to make decisions for themselves. It also helps to ease the burden on families and carers by providing clear guidance on the individual’s wishes.

A good example of a care plan which includes an advance care plan can is provided by Devon County Council here.

What is a 'This is Me' in the Care Plan?

‘This is Me’ is a person-centred care planning tool that is used in healthcare settings. It is a comprehensive profile of an individual that helps healthcare providers understand their unique needs, preferences, and goals for care. The profile typically includes information such as the person’s background, interests, likes and dislikes, strengths, and areas of support they need.

The ‘This is Me’ tool is again designed to promote person-centred care and so endeavours to put the person receiving care at the centre of their own care, rather than focusing solely on their health conditions or medical treatments. By creating a ‘This is Me’ profile, healthcare providers can gain a deeper understanding of the person’s individual needs and preferences, and use this information to tailor their care and support to their unique circumstances.

‘This is Me’ is a useful tool for care planning, as it promotes person-centred care and helps healthcare providers understand and meet the unique needs, preferences, and goals of the person receiving care.

A great ‘This is Me’ tool template is provided by the Alzheimer’s Society here.

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