Care Plans

The following is a recommended intervention identified by the TP-CKD programme for implementation with both staff and patients, to test the following question:

Can the use of intervention tools help to improve the knowledge, skills and confidence of patients with kidney disease to enable fuller participation in the management of their own health?

To explore other interventions identified by the programme, visit our Interventions Toolkit Home Page

Care Plans

Personalised care-planning is an essential component of effective supported self-management. People need to be supported to express their own needs and decide on their own priorities through a process of information-sharing, shared decision-making, goal-setting and action-planning. The emphasis on care-planning should be on proactive interventions to keep people as healthy as possible. The Department of Health have mandated that all people with a long-term condition have a ‘care-plan’ by 2020 (NHS 5 Year Forward View).

Care plans have been in existence for many years and there are many good examples. In general though it seems that, as currently practised, they are often complex documents, difficult to implement and not always reflective of a shared approach to decision making. Care plans should reflect mutually agreed goals and actions, by patient and health professional, and be updated regularly.  Such plans can support partnership working and increase patient self-efficacy behaviours.

In its most basic form the care plan could be part of a letter addressed to the patient and copied to their GP (see Changes to Practice) which paraphrases the conversation which took place during a consultation and sets out the agreed goals and actions. This would also be available on PatientView. We recommend this simplified approach.

Useful Links and Resources

Click here to view a template ‘Letter to Patient’, designed by Kings College Hospital Renal Unit (Cohort 1)

People in control of their own health & care – The state of involvement. The kings fund in association with National Voices – November 2014

The personalised care planning e-learning course has been developed on behalf of DH by NHS Employers and is delivered by HEE e-Learning for Healthcare.

The Kings Fund: Delivering better services for people with long term conditions.