Introduction to care planning

Care planning is a simple concept but there are many important details to consider when putting it into practice. Care plans are essential documents, both for the care provider and the service user. But making a bad care plan can have serious consequences, including inefficient service, wasted resources, poor inspection results, reputational damage and in extreme cases, ineffective care can be life-threatening or can lead to the closure of a business. If you’re new to care planning you may be wondering if there’s a right and wrong way to compose a care plan, what the dos and don’ts are, should you use paper or find a digital care planning software, what are the benefits and how can technology help? This introduction to care planning will give you a good idea what to expect and what is expected from you.

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What is care planning_Intro


What is care planning

What is care planning?

Care planning is the process of documenting the health and care needs of an individual and providing guidance on how to best support them. With a care plan in place, any caregiver will be able to quickly find the information required to give consistent and quality care for an individual. You can produce a care plan on paper or by using a computer (digital care planning), but whatever option you decide, it’s essential the care plan is easily accessible to the people who need it.

To provide maximum benefit, care plans are normally created following a care assessment to ensure there is adequate and accurate information to help you fully understand the strengths and limitations of the individual or potential risks. The assessment stage is a key opportunity for the carer and individual to have a conversation about health, goals and expectations. 

When the care assessment is completed, a draft of the care plan should be composed with further input from the individual to make it as personalised and accurate as possible. This practice is also what makes a care plan ‘person-centred’. Both parties should be satisfied before approving the final care plan, and it must be reviewed regularly to monitor progress and identify when changes are needed. The care plan should offer a comfortable, efficient and effective service, benefitting the care provider and receiver. 

The importance of care planning

Care planning is essential for providing the best possible care to your service users. It allows you to explore a wide range of health areas in detail to better understand each individual’s requirements and conditions. A well-developed plan will aid you with establishing an efficient, effective service while safely managing risk. 

By working together, you and your service users can set long term goals that will be supported by the right levels of care so resources and time are not wasted. A plan that recognises the unique abilities of each individual will help the people in your care live independently, continue enjoying activities and pursuing interests. The care will also be consistent, so no matter who is on shift, the service being delivered should meet the individual’s expectations. 

What is care planning_The key steps to care planning

The key steps to care planning

Creating a thorough care plan takes time and effort. There are no shortcuts to getting the care plan right – you need to collaborate, record, develop, personalise and monitor your plans. However, using care planning software you can remove admin work from the process without affecting the quality of the plan. In many cases, care planning software can offer you extra time so you can make sure the care plan is as comprehensive as possible. Here are the four key steps to care planning:

1. The assessment

Before you create a care plan you should first perform a thorough care needs assessment covering all areas of care (personal hygiene, mobility, communication, etc.) to discover the strengths, limitations and goals of the individual. The assessment you use should be relevant to the service users you specialise in caring for and the answers you record must include as much detail as possible. 

2. Drafting the care plan

When you have completed the assessment and have a strong idea what you and your client want to achieve you can then draft the care plan. Go through each area of care and decide how you can best provide your service, taking into consideration the individual’s abilities while managing all possible risks. Personalise the plan and ask your client to contribute where you feel is necessary. 

3. Finalising the care plan

Read over the care plan with your client to ensure you are both satisfied and it’s as person-centred, efficient and effective as possible. After it has been approved, you can begin using it to guide you through their day-to-day care without losing sight of the overall goals. 

4. Monitoring progress

A care plan is an ever-evolving document that adapts to the needs of the client. It’s crucial to review your care plans regularly and ensure they are having a positive effect. If a plan isn’t working as you intended, discuss making changes with your service user and slowly amend it until you receive the outcome you both want. 

The benefits of care planning

A care plan is a powerful tool with multiple benefits for the care provider and receiver. Person-centred care plans in particular are designed to help you deliver consistent levels of care and maximise your resource so you reach a desired result faster. The assessment stage of care planning allows you to explore and record in detail the different aspects of care needed to support a diverse population with different complex needs. 

Working directly with your service user to create a rewarding care plan will make sure they are onboard and totally comfortable with your service. Letting your service user make small choices for themselves is a simple but invaluable way to encourage them to take more control over their lives and grow their confidence while moving towards a common goal. For staff, having this structure in place makes the work more efficient, organised, promotes teamwork and generates a greater rapport with service users. Overall, this leads to greater job and care satisfaction. 

Care planning records

Historic versions of care plans help demonstrate previous care to aid you in monitoring progress over long periods of time. For example, if your current plan isn’t as effective as it could be, by comparing older records you might be able to fine tune it based on your previous service. Like all care records, you are able to also evidence your care standards in the event of an inspection so you can prove how you have provided effective care and met the changing needs of an individual. 

Person-centred care planning

Person-centred care planning is the key to providing the best possible care for your residents. This practice ensures your residents will receive care that is tailored to their specific needs and that your service is efficient and effective. To achieve this, your residents must feel comfortable speaking freely about their concerns and ambitions, and you should work with them to accomplish their goals while offering a first-class service.

The best way to accommodate this is through a care assessment, which is essentially a recorded dialogue between you and your resident. By asking a series of relevant questions regarding different aspects of their health and care needs, you can gather enough information to create a plan of care bespoke to each individual. Person-centred care plans should be monitored and updated regularly to ensure the current service is producing the desired results while continuing to represent the changing needs of your residents. 

What is care planning_Paper vs digital care planning

Paper vs digital care planning

Paper systems have traditionally been the go-to method for managing all things care. Picking up a pen and paper to perform a care assessment, create a care plan or record healthcare has for decades been standard practice. However, in recent years there has been a strong push to highlight the benefits of implementing technology into care settings, with care planning technology being a major component that is transforming how we care for people. 

Keeping paper versions of care plans, including historic records, can take up vast amounts of storage space. The more paper you have, the longer it takes to locate what you need and there’s a risk that paper may become misplaced or damaged. One solution is to manually scan your paper care plans into your computer to view digitally but this requires a lot of work to keep on top of, and you need to come up with a system that allows you to find what you need quickly. Simply saving your documents inside folders will get the job done but ultimately it won’t offer the same benefits as using a professional digital care management system

Digital care management systems that specialise in care planning will allow you to perform the assessment and create the care plan efficiently and directly through the computer and automatically saves it in easily accessible dedicated virtual space. Many systems, including CareDocs, incorporate numerous additional options you don’t otherwise receive by scanning your plans into a computer. For example, locating certain care plan sections, care plan editing, viewing historic records, writing footnotes and finding specific information using digital reporting can all be accomplished in a handful of clicks. 

While the majority of care providers still use paper systems, the market for digital care planning software is growing each year. This is due to more people discovering its benefits, ever-improving technology capabilities, more cross-platform integration and lower competitive costs. However with all the positives of using a digital system, it can be difficult to transfer your work from one software to another if you change your mind so it’s incredibly important to make sure the system and provider you choose are right for you. 

Care planning software

If you’re looking for care planning software, at first glance you may think you’re spoiled for choice. There are numerous companies who seemingly offer the same product, so it’s difficult to know which one is the best choice. Luckily, you can narrow down the results if you know what to search for. 

The first thing you should check when browsing the market is whether the product was specifically designed for your business type. For example, residential care homes for elderly people, children or domiciliary care businesses will have different care requirements. If you spot a care planning software which claims to be a good all-rounder or adaptive to any care discipline, there’s almost certainly a more effective product available for you. 

There are just a couple different types of software which allow you to build digital (electronic) care plans. In some cases you may come across a software dedicated solely to offering a care planning feature. If this is all you need, it could be the best option. However, most software providers will offer cost-effective packages that contain multiple benefits and features to help you digitally transform your business. These products are called digital care management systems, and if you opt for one of these, ensure the option you choose has a focus on person-centred care plans. ‘Person-centred’ is the key phrase here. If there’s no mention of this, you will most likely end up with a poor quality product. 

Likewise, the software provider also has to appeal to you. They could have the best product on the market but if they don’t show they can properly support their customers, you could be left confused with little understanding of the software, causing you to backtrack to paper systems due to a lack of communication. Testimonials and case studies are the best resources you can read to really get to know the company you want to buy from. You ideally want to find a supplier who will walk you through the transition step-by-step and offer you free on-going support and flexible training. 

When you find a supplier and software which look like a good fit for your business, always book a free demo before committing to anything. You need to see the product for yourself to really know whether it can meet your needs and provide the solutions you’re looking for. There are plenty of great products with free demonstrations so don’t consider paying for one if asked. If a business charges you for basic services like this, there’s a decent chance they will charge you for other essentials later down the line. 

Beware of hidden costs for unadvertised add-ons or new features that you may not realise you need in the beginning of your subscription. For example, some providers might entice you with low costs or even free care planning software (or free trials), only to start revealing their charges once you have invested a lot of time, trapping you into a bad deal. At CareDocs, we give you an exact cost and all of our system services are included. You also have the option of hiring more desktops, laptops or mobile devices at an additional monthly rate, and we can walk you through this option at the time of set up. 

What is care planning_Using technology to help with care planning

Using technology to help with care planning

Switching from a paper care planning system to a digital care planning system should offer several immediate benefits. Good quality systems will have been designed to ensure the process is more efficient overall, including saving time and providing a platform where creating and editing plans takes less effort. 

Most reputable providers, like CareDocs, have care sector experts on the team that work very closely with the software developers to ensure your digital care plans are highly person-centred. Contrary to common belief, just because some elements of the creation process are faster, it doesn’t mean there will be an impact on the quality of the product. The main idea is to allow you to produce high quality care plans with less administrative work so you and your residents benefit from an enhanced and comfortable care experience. 

Because your care records are all stored digitally in one system, searching for and accessing your care plan information is as easy as navigating to your residents’ profiles and clicking on the care plan section. Most digital care planning software providers will have a dedicated feature for this, so you will quickly become familiar with a consistent user-friendly layout, helping you locate the information you need in as few steps as possible. 

Some systems have online platforms to help you access your care plans online. For example, CareDocs Cloud Portal is an additional service included at no extra charge with the CareDocs Cloud package. The portable version of the main system was created to give you the ability to view information from mobile devices and outside of the office. 

Digital systems can also automatically alert you when updates are due or if care plan is outdated so your residents continue to receive the best possible care. Offering consistent and effective care will help your business remain compliant with regulatory requirements and demonstrate that your setting is well managed. 

Instead of looking through filing cabinets for historic care plans, a good system should allow you to scroll through previous versions of care plan sections at the click of a button. This helps you quickly evidence previous care to see your residents’ progress over time in and provides an audit trail of the quality of your work, without needing to use precious physical storage space within your setting or distract staff from more important work. 

Having a digital system means there’s no paper, unless you choose to print certain care plan sections. Accessing your work on a laptop or mobile device saves you from carrying cumbersome files around and keeping them organised, in addition to saving money and resources on re-stocking stationery. You can also export your care plans to PDFs to share with external health professionals, or add them to your Emergency Admission Packs to ensure you’re fully prepared to provide urgent information. 

Implementing technology like a care management system should transform your business by making your service more effective through increased efficiency and a consistent person-centred approach to care. With many leading software providers offering cost-effective products, and taking into consideration you will save money on paper and stationery while maximising your resource, it could end up saving you in the long run. 

Common care planning mistakes

Care plans should be personalised to each resident. A blanket approach to save time is not effective. In the long run, ineffective care will cost you time and resources. To help you achieve a person-centred care plan, your residents should be involved in the creation of the care plan, both throughout the assessment and, if necessary, when personalising the final draft to ensure you are both happy with the plan. 

Including too little or too much information can confuse the person reading the care plan, which may lead to human error or a poor service, for instance asking the resident to clarify details or repeat themselves. Ineffective care plans also tend to focus primarily on a resident’s weak points, but it’s only through recognising what your residents are capable of, you can use their abilities to increase confidence and aid them through the care process. 

Try to identify and tackle the wider issues at hand instead of focusing on short term solutions – there’s the chance the issue will return eventually. Only use factual information instead of guessing or changing data to reach your preferred outcome. If you notice the care plan isn’t achieving the desired result, don’t repeat your actions and expect the outcome to be different. Adjust your plan using a trial and error approach until you notice subtle positive changes and keep working in that direction. 

Top tips for care planning

Care plans should be completely person-centred, meaning they are tailored to each individual. This includes the phrasing you use – for example, ‘Robin is at low risk of developing pressure injuries’ as opposed to ‘he is low risk’. If you were reading the care plan aloud to another member of staff, using their name would make the individual feel more included. Simple details like this will help toward ensuring people are treated with respect and dignity.

Work together with your service users and encourage them to make choices where appropriate or state their preferences. This will give them more control, build their confidence and will stop people repeatedly asking for the same information. The more detail you provide in the assessment and care plan the better, but try not to overcomplicate it or use confusing language.

When you are putting goals in place, such as treatment or physical therapy, make the steps small and realistic – setting your clients up for failure can cause major setbacks. Learning a person’s limitations is essential for managing risk but you should put a heavy focus on their strengths and abilities to empower and encourage your clients to be active.

Care plans should be easily accessible to people who require it and reviewed regularly to ensure they remain effective. Remember to keep your plans as factually accurate as possible. They are used to evidence the levels of care you’re providing and writing unhelpful or untrue statements will have negative consequences for you and the individual. 

Download your free ebook!

Don’t forget to grab your copy of our free Introduction to Care Planning ebook…

If you would like to learn more about CareDocs and the benefits of our market-leading care planning software, please book a free demo

Originally published on May 7, 2021
Article updated on November 9, 2021

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