campaspe pcp getting started with care planning campaspe primary care partnership
TRANSCRIPT
Campaspe PCP
Getting started with Care Planning
Campaspe Primary Care Partnership
Objectives
To demystify Care PlanningTo increase understanding of care
planning and where it fits in practiceTo introduce the types of care plans To define the role of a key worker or
care coordinator
ContextService Coordination
Statewide approachPlaces consumers at the centre of
service delivery4 operational elements of SC are
Initial Contact; Initial Needs Identification; Assessment and Care Planning
Care Planning key work area of the Service Coordination Steering Committee and PCP Strategic Plan
Operational elements of Service Coordination
Resources
Victorian Service Coordination Practice Manual – 2009 (update due in July 2012)
Good Practice Guide 2009Continuous Improvement FrameworkService Coordination Tool Templates -
2009 user guideLocal Key Worker Roles &
Responsibilities document
Websites
www.campaspepcp.com.au
www.health.vic.gov.au/pcps/coordination
What is Care Planning?
Dynamic processInvolves negotiation, decision
making and goal settingRelies on good communication
between consumer, service providers and GPs
Care Planning ObjectivesPlanned, evidence based and person centredActively engage consumers in planningConsider social, emotional and health issuesBased on needs goals and actionsIncludes education and self management
interventionsMonitor and review progressUnderpinned by good communicationMeets legislative requirements
Benefits of Care PlanningAssist consumers to set goalsEncourages consumer involvement and
self-managementManages and monitors long term careProvides a checklistDocuments information e.g. action plansEncourages team approachesIs proactive rather than reactiveIncrease consumer awareness of services
Person-Centred Practice Principles
Partnership approachHolisticOpen communicationRespect and privacyInclusive of family and carersSupports self-management and
responsibilityParticipation in decision makingSupports autonomy
Types of Care Plans
Service SpecificIntra-agencyInter-agency
Service Specific Care Plan
This is a care plan developed by a single service
The consumer has one or more issues that can be managed with support of a single program area
• District Nursing treatment plan• Physiotherapy treatment plan• GP Asthma management plan
Intra-agency care plan
Require multiple services from a single organisation
Individual service specific care plansOverarching intra agency care planRequires key worker; eg.
Diabetes Services care plan HACC services plan
Inter-agency Care Plan
Consumer has range of chronic, complex &/or multiple issues
Involves separate agencies3 or more ongoing service providersKey worker
Complex care planCAPS case management care planGP team care arrangementsTransitional care plan
Elements of a Care Plan
1. Date2. Participants3. Consumer stated issues4. Consumer stated goals5. Agreed actions & service responsible6. Timeframes7. Review dates8. Consumer acknowledgement9. Actual review date
SCTT Care Coordination Plan
Issues to consider
Consumer stated or agreed issues
Do all consumers need all the care plans
Who is the key worker
Role of the Key Worker
Engagement and empowermentConsolidate informationService system knowledgeDocumentation of plan and
monitoringCommunication and liaisonFacilitating case conferencingProvision of feedback
Local documentation – Support guideCampaspe Care Planning Key
Worker Roles and Responsibilities document provides info on;o What is a care plan &
definitions o What is a key workero Steps in developing a CPo Roles and responsibilities
of the key workero References to tools/forms
to use
Goal Setting
Linked to problem/issueWritten in positiveWritten in the consumers wordsSMARTCan be maintenance goalsShould not be interventions
Setting Goals and Action PlanningSomething the consumer wants to
doAchievableAction specificAnswer what, how much, when, how
often?Confidence level 7 or more
Goal setting – practice example
Overall aim to lose weight.Goal
Specific- aim to help lose weight by increasing the amount of walking
Measurable- walk for 30 minutesAchievable- confident that could manage to
walk for that longRealistic- need to take the dog for a walk so
will be the motivation I need. Timely- will walk 3 times per week in the
afternoon
Conclusion
Care planning is part of service coordination
Each service will have specific involvement with care planning
Know what your role is?Be familiar with the documentation
Final point
It may seem time consuming but the aim of service coordination is to ensure the consumer receives the right help at the right timeby the right person
BE CONFIDENT IN YOUR ROLE IN THE CONSUMERS JOURNEY