care planing

Topics: Health care, Nursing care plan, Person Pages: 6 (2170 words) Published: October 31, 2014
improving care for people with
long term conditions

information sheet 1

personalised

care planning


an ‘at a glance’ guide for healthcare professionals


personalised care planning
improving care for people with long term conditions


About this information sheet
This information sheet describes what
personalised care planning is and what
good care planning looks like as well as
what it means for individuals and healthcare
professionals.

Who should read it?
Anyone involved in delivery of healthcare to
someone with a long term condition, including
doctors, nurses, allied health professionals,
those delivering personal health budgets and
health trainers.

What is personalised care
planning?
Personalised care planning empowers
individuals, promotes independence and helps
people to be more involved in decisions about
their care. It centres on listening to individuals,
finding out what matters to them and finding
out what support they need.
Personalised care planning is essentially about
addressing an individual’s full range of needs,
taking into account their health, personal,
family, social, economic, educational, mental
health, ethnic and cultural background and
circumstances. It recognises that there are
other issues, in addition to medical needs, that
affect a person’s total health and well-being.
It is therefore a holistic process, treating the
person “as a whole” with a strong focus on
helping people, together with their carers, to
achieve the outcomes they want for themselves.
In doing this, it should open up more choices
that are relevant for people with long term
conditions. This is demonstrated well in the
delivery of personal health budgets.

70% of individuals with a long
term condition say their care has
improved as a result of personalised
care planning.*

What does good personalised
care planning look like?
Good care planning can make a huge difference
to people’s lives. It enables individuals with
long term conditions to plan their care, have
strategies in place to cope with exacerbations
of their condition and have all the relevant
information they need to make informed
choices and decisions. Supporting people to
self care means they have more confidence and
control over their condition and understand
how it affects their lives.
Individuals with long term conditions will be
at different stages on their journey and their
ability to take more control will depend to
some extent on what stage of that journey
they have reached. Someone who has just been
diagnosed with a long term condition will have
different needs to someone who understands
and has accepted their condition, or someone
requiring end of life support. Depending
on the complexity of the person’s need, a
multidisciplinary team of staff may be involved
in the care planning process.
As a minimum, a care planning discussion
ought to focus on:
• agreeing the individual’s goals (e.g. I want to
lose weight, stop smoking, get out more, get
a job);
• providing information (timely, relevant,
ongoing, could be in the form of an
Information Prescription);
• supporting individuals to self care, to take
a more active role in their own health;
*GP

Patient Survey 2009/10

2

improving care for people with long term conditions

• agreeing on any treatments, medications,
or other services such as access to support
groups or structured education programmes
such as the Expert Patient Programme;
• agreeing any actions;
• agreeing a review date.
Successful personalised care
planning needs to be developed
with individuals, not done to them.
It requires you to adopt a different
role to the traditional “diagnoser and
treater”. The healthcare professional’s
role is to support individuals to
acknowledge, understand and adapt
to living with their condition.
Please see information sheet 2: Personalised
care planning diagram, which is designed to...
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