Care planning is the process of developing a care plan for an individual by setting patient-centred goals, developing strategies, outlining tasks and setting schedules in order to accomplish the goals.
Here are four key steps to care planning:
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1. Patient assessment
- Patient identified goals (e.g. walking 5km per day, continue living at home)
- Hobbies, interests, routine
- Motivating factors (patient’s values, beliefs)
- Patient-identified problems, past medical history
- Physical and mental health (observations, screening, assessment)
- Social factors (social supports, finances)
- Safety factors (falls risk, home safety, competence)
- Advance care planning considerations
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2. Planning with the patient
- How can the patient achieve their goals? (education, intervention, support)
- Has the patient’s readiness to change been considered?
- What interventions are going to help? (Nellie, health coaching, social prescribing)
- Who will be involved and what are their responsibilities? (patient, care coordinator, GP, nurse, allied health, social and community supports, specialists)
- How will the patient’s goals be monitored? (schedule reviews, meetings)
- Document care plan, action plans, referral and review appointments and share with the patient and their team.
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3. Implement
- Formulate action plans in collaboration with the patient and other service providers (e.g. COPD action plan, exercise plan)
- Commence interventions and/or refer to services and supports
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4. Monitor and review
- Stay in regular contact with the patient and provide feedback to the GP and wider team about the patient’s progress.
- Regularly review the patient's care plan to see if it is helping them to meet their goals.
- Monitor status of referrals made to other services.
Care planning tips
- Consider the patient’s choices and preferences
- Consider whether the patient is ready, willing and able to change
- Include small, manageable steps
- Clearly show the patient who is responsible for actions in the care plan
- Use easily understood language
- Set realistic time frames so measuring achievements is possible, and patients can remain motivated.
Action plans
Action plans can be a set of instructions that explain to patients what to do if their health suddenly declines, relating to a specific medical condition. All patients with a chronic disease, who are at risk of hospitalisation should have one. They are also known as anticipatory care plans. Action plans help patients to recognise and manage any worsening of their symptoms and reduce unnecessary hospital admissions. They can give patients the confidence to know what to do in a health event and empower them to manage their conditions.
Action plans can also be a self-management plan e.g. blood glucose monitoring, to assist preventable symptoms and outcomes. For an action plan to be used effectively by the patient, they need to be written in collaboration with them, using language that they can understand.
These plans help the patient to:
- Develop a partnership with their doctors and other health professionals
- Access further health information
- Become more involved in the management of their own health
- Monitor symptoms and measures
- Adopt habits that can improve their quality of life
Action plans are different to Advance Care Planning (ACP), which is the process by which individuals discuss their wishes and preferences about their healthcare with their family and health care providers. Advance Care Directives (ACDs) are an individual’s record of these wishes and preferences. ACDs are used when patients are unable to communicate their wishes and preferences for themselves. Read more about Advance Care Planning.
Action plans can be embedded within a GPMP, Team/Shared Care Plan, or they can form a separate document. This depends on the needs of the patient and individual practice requirements.
After-hours arrangements
All care plans should explain to a patient what they should do if they fall ill outside of their general practice’s regular business hours i.e. their after-hours arrangements. Documenting a patient’s after-hours care arrangements can help reduce potentially preventable hospitalisations and give patients a sense of control over their health.
See TCA and GPMP Example Templates that include after-hours arrangements on our
Care coordination tools, templates and links page.
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