Three: individual care plans
Everyone diagnosed with a long-term
condition should be offered a personalised care
plan. Care plans should be tailored to the individual’s
needs and circumstances and reflect their personal
choices and preferences. Care plans need to be
developed through partnership between patients
and health professionals and should help patients
understand what they can expect from services
and when.
Personalised
care plans have been incorporated into a number
of the Government’s recent national service
frameworks.They represent a written summary of
the negotiated agreement between service users
and providers.
An
indiviual care plan should:
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provide
a written summary of the shared aspirations
and goals that people have agreed with their
professional and informal carers. They should
be person-centred and focus on social issues
and quality of life, as much as on service
interventions |
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match
the individual’s particular condition,
personal preferences and choices with the
best services and support available to maximise
their quality of life |
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set
out what individuals could do to maximise
their own quality of life |
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be
reviewed regularly to check needs have been
met and to identify changing needs. Changes
should be made by joint agreement. Unmet needs
resulting from failure of service provision
should inform future planning and commissioning |
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belong
to and be held by the person with long-term
conditions, forming part of their electronic
patient record |
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be
communicated to all those who will deliver
care. In this way, it should contribute to
greater seamlessness between services |
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name
a professional who is accountable for the
delivery of services agreed in the plan. |
Care
plans will enable people to manage their own condition.
People’s confidence in their own skills
can be further boosted through lay-led self-management
programmes. Participants in these programmes develop
skills to help them gain confidence, enabling
them to play an active role in shared decision-making
and in shaping local services.
By the end of the next Parliament
Everyone
with a long-term condition should
be offered a personal care plan and
should be offered a choice of appropriate,
convenient and accessible lay-led
self-management programmes.
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