Care Planning Processes in Healthcare Practice

Unit 20: Care Planning
Processes in Healthcare Practice
Care planning and the core care principles
Care pathways and care bundles
Individuals views are listened to and treated with respect
Evidence-based approaches
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Care bundles
Care-bundles are a composite of synergistic interventions to improve
clinical outcome for a condition, containing a few essential, wellaccepted components selected based on best evidence, local
considerations, and open to change with time and experience. A carebundle ensures the application of all relevant interventions is
consistent for all patients at all times.
Care planning
Involves effective assessment
Care-planning discussions- between patients and professionals
Addressing the individual full range of needs
Focus on goal-setting
Supporting self care
Assessing risk
Planning care
Specific goals
Time limited
Continuous assessment
Work and plan care treatment with others who provide care and treatment for the patient.
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Process of care planning
Care panning is done by appropriately trained and qualified professionals
Care plans are focused on recovery and promoting wellbeing
Staff use a compassion-focused approach
Care planning can take place in an appropriate and safe environment
according to individual need
Care Plans are shared with everyone concerned Individuals have an equal
opportunity to be involved in planning care.
Care planning is sensitive to diverse needs, is produced in an accessible
Those listed in the care plan have agreed to provide the service Avoiding
unwarranted variation
Assessment process
Assessment is an important process of care planning in any area of care.
Assessment should be
be a joined-up process between health and social care, facilitating joinedup care planning and delivery of care
• have a named professional leading the process and coordinating services
• be person centred
• be collaborative
• be holistic and recognise potential conflicts
• be based on outcomes
• simplify the processes
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Types of assessment in health and care
Care planning, care pathways and care bundles, e.g.
Care needs assessment
Holistic assessment
Outcomes based assessment
Risk assessment
Joint assessment
Face-to-face assessment
Structured interviews
Evidence-based assessment.
Single Assessment Framework
Evidence-based assessment
Evidencebased assessment (EBA) refers to the use of research and theory to guide the
selection of constructs to be used for a specific
assessment purpose and to inform the
methods and measures used in the
assessment process.
Sources of evidence can include the following:
Direct observation with service users
Communication with practice supervisors
Documentation, such as a practice assessment document or ongoing record of
Communication with any other practice assessors
Communication with anyone else who may be involved in the education of the student
Communication with the academic assessor
Professional self reflection
Communication and an ongoing relationship with the service users
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Common Assessment Framework (CAF)
The Common Assessment Framework (CAF) for Adults is not a new
assessment process. Its aims are to provide a framework that updates
the principles for good assessment, taking account of the
developments in personalisation and in health and social care, and to
support this with effective approaches to information sharing
between health, social care and the third sector.
Health Needs Assessment
Health needs assessment tool A health needs assessment (HNA) tool
developed by NHS Kirklees helps healthcare professionals to identify
the needs of the individual and target resources more effectively,
offering more personalised support to individuals with long term

Holistic Assessment
Assessment of patients and families with life-limiting illness involves
the nurse needing to understand how the disease process impacts on
all areas of their lives
Assessment involve the persons physical, psychological, social ,
spiritual and emotional.
Holistic assessment involves understanding the relationships between
these elements and although they may be assessed separately they
all contribute towards the whole experience and person.
Care planning processes in healthcare practice
Lo2: Implement care plans in workplace to meet desired outcomes for the
Learning objectives: at the end of this lecture learners will be able to:
Identify and discuss their responsibilities in planning PCA.
Demonstrate their contribution in the care planning process.
Demonstrate promotion of holistic well-being through effective communication
Able to review the application of risk assessment in promoting PCA.

Roles and
Duty of care
Holistic approach
Focus on individual- values and choices
Autonomy and empowerment

Contributions to care planning process
The essence of care planning is about healthcare staff doing the following:

Engaging with individuals
Encouraging their input and views
Finding out how they could really make a difference to support their health and
Successful personalised care planning needs to be developed with the individual
and not done for them


Contributions to care planning process: Class activity
Create a hypothetical case study and use that to develop a care plan that reflects

person-centred approach. Specifically highlight your various roles that reflect personcentredness.
How health and social care professionals can contribute to care planning
Health and social care professionals’ roles include:
Agreeing with the individual’s goals
Providing information (timely, relevant, ongoing)
Supporting individuals to self care and to take a more active role in their own health (ongoing support)
Agreeing action on any treatment, medication and access to other services
Agreeing a review date
Supporting the individual to acknowledge, understand and adapt to their living condition

How health and social care professionals can contribute to care planning
Develop and apply clear assessment methods
Ensuring that the right procedures are followed
Working in partnership with other stakeholders
Accurate record keeping and data protection
Being proactive rather than reactive.
Class activity
Identify and discuss your responsibilities in planning PCA.
Why do you think that it is necessary to play such roles?

Effective communication in holistic care planning processes

Effective communication in care planning involves:
Listening to the individual

Supporting the individual to make informed choice by providing information
Supporting individual to access appropriate information
Effective communication in care planning involves:
Discussing risk
Asking individuals about how they feel about the need to self manage their care
Asking the individuals if they have ideas as to the services they would like to
include in their plan
Risk assessment and person-centred planning
Dealing with the identified risks
Recognising norms and implications of deviations
Reporting concerns effectively.
Checking accuracy in measurement and recording
Setting realistic targets