A personalised care and support plan should be seen as a book with chapters. We all have different chapters depending on what’s going on in our lives.
The plan is about bringing all of the various chapters together electronically so that health and care teams can be aware of this information and share amongst different services. This means we can better support someone’s needs and not have to ask them to repeat the same story over and over again.
Personalised care and support planning is a series of conversations in which the person, or those who know them well, actively participates in exploring their health and wellbeing, within the context of their whole life and family situation.
This process recognises the person’s skills and strengths, as well as their experiences and the things that matter the most to them. It addresses the things that aren’t working in the person’s life and identifies outcomes and actions to resolve these.
Personalised care and support plan is the umbrella term used to describe the many different personalised care and support plans held by various teams and services. For example, an Advance Care Plan, a Stroke Journal, a Cancer Holistic Needs Assessment (HNA) and the What Matters to Me Plan... are all personalised care and support plans. All plans must be aligned with the national NHSE/I criteria, as below:
- People are central in developing and agreeing their personalised care and support plan, including deciding who is involved in the process.
- People have proactive personalised conversations which focus on what matters to them, paying attention to their needs and wider health wellbeing.
- People agree the health and wellbeing outcomes they want to achieve, in partnership with the relevant professionals.
- Each person has a sharable personalised care and support plan which records what matters to them, their outcomes and how they will be achieved.
- People have the opportunity to formally and informally review their care plan.
- People have a single plan that is owned by the individual and accessible to those supporting the person.
To find out more about Personalised Care and Support Planning please follow the link: Personalised Care and Support Planning
