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Care Planning: How often should I review my care plans?
“How often” must be the most asked question about care planning . Many people who are charged with care plan management and who are quite confident in most aspects of care planning seem to find their confidence lacking when it comes to deciding how often to review them.
Realisation that getting the review period “right” is something that any auditor or registration inspector will look for adds to the stress levels.
The answer is confused by the fact that the old Minimum Standards in England used to talk of a review period of “at least monthly”. This statement appears to suggest that it is possible to decide on a single time period after which the care planner sits down with all the care plan files and reviews them, and then makes a note to do them all over again in, say, one month’s time. Nothing could be further from best practice, other than maybe not reviewing at all.
The next step in understanding was to realise that the instruction to regularly review should be applied to an individual service user, not all service users, and therefore the review period for one service user could differ from that of another, who has differing needs.
But neither approach comes anywhere near adequate practice, for which we need to step back and remind ourselves how the care plans for an individual came into being. Each plan of care was originally written because when a risk assessment was carried out with the service user, the assessor and the service user identified something, call it a need for now, which needed some managing in order for the quality of life and/or health of the service user to be maximised or optimised. Each plan of care will be a result of one risk, or at the very most a small number of very highly linked risks, and each service user will have a number of plans of care, one for each risk. For example, an older person may have plans of care for risks such as: (examples using the QCS care planning format)
- Hearing loss, from the Health assessment
- Diabetes, from the Health assessment
- Mobility problems, from the Health assessment
- Medications management, from the Health assessment
- Terminal care wishes, from the Cultural, Religious and Palliative care assessment
- Skin integrity management, from the Skin Marks/Bruising Assessment Tool
- Continence management, from the Personal Care Needs Assessment Tool
- Short term memory loss, from the Personal Care Needs Assessment Tool
- Anxiety, from the Mental Health Assessment Tool
- Emergency evacuation help, from the General Risk Assessment
- Moving and handling, from the Moving and Handling Risk Assessment
- Nutrition management, from the Nutritional Risk Assessment
- Falls risk, from the Falls Risk Assessment
- PRN medicines management, from the PRN medication Plan of Care
This person will have 14 separate plans of care, each using the format in the QCS care pack. And this person, it has to be noted, has quite simple needs. Scanning the list, it is immediately obvious that the review period for each plan bears no relationship to any of the others, and that therefore each must have a review period set which is dependent on that particular risk, and a judgement of how quickly or otherwise the underlying need is likely to change. For instance, hearing loss will require less regular review than skin integrity management. Falls risk, may require more regular review than terminal care wishes. And so on.
The obvious conclusion is that the care planner must look at the individual risk for the individual service user, and come to a professional judgement as to how long the current care plan can be allowed to carry on before it is in danger of becoming ineffective due to the rate of change of the assessed risk. For hearing loss, it is probable that the review can be carried out monthly without any added risk. Skin integrity is likely to require much more frequent review, possibly daily, if the danger of skin breakdown is to be effectively managed. Bear in mind also that reviewing one risk may well set off a cascade or reviews of other, related, or causative, risk assessments. Taking the falls example; a review of the falls prevention plan of care is quite likely to lead to an immediate physical assessment, review of the nutrition plan, the medications plan, the moving and handling plan, the mental health plan, and the room risk assessment, in order to arrive at a holistic management plan for the falls risk.
Setting an individual care plan review period for each of the 14 plans of care in this example can be regarded as good practice, but passive review.
More effective care planning is active, not just passive. Take for example the falls risk listed above. What should the care service do if the care staff start to record a noticeable increase in the frequency, or the severity, of falls incidents by this particular service user? Wait for the next planned review? Of course not; each falls incident should result in an immediate review of the plan of care for falls. After all, the objective of the falls plan of care is to at least reduce the consequences of falls, if not the actual incidents of falls. If a fall occurs, there is an immediate need to review the consequences of the fall, and find out why the current plan of care failed to prevent it, or at least reduced its effect.
Other assessed needs which are likely to change at random intervals, and therefore need dynamic reporting and plan of care review include:
- Following a visit from an external specialist, e.g. GP, District Nurse, other professionals.
- Episodes of illness e.g. infections.
- Episodes of irregular bowel behaviour
- Emotional upset
- Any alteration to health state.
In order for this level of active care plan review to happen, all staff must be aware of the process, that is, they must be trained in an understanding of care planning. Staff need to know the reason for daily reporting to be aligned to the care plan, rather than the often-seen chatty essay which imparts no information about the effectiveness of the care plan. Or the even more often seen “nothing to report”. If there is nothing to report, presumably the care was delivered as specified, and was as effective as planned; if that is the case that is what should be noted. Otherwise the care plan reviewer, when reviewing the records, cannot tell if the note was good news, or simply an acknowledgement that the person making the note actually had no information. If staff are aware of the reasons for excellent recording of care delivered, and how to properly record it, the reviewer has an appropriate level of information available to them when the review is carried out.
There is no simple answer therefore for the question “how often do I review the care plans”. There are as many answers as there are plans of care, and if the care plan is adequately compiled, there are likely to be a lot of those. And, the frequency might well change from time to time. Care services deal with real people, whose needs probably are changing over time and therefore constantly changing the need for review. Even those service users whose needs are long term stable will have good and bad days, requiring sensitivity and willingness to change the approach in the plan of care.