What techniques can you use to develop a care plan with patients and families?

1 Assess the situation

The first step in developing a care plan is to assess the patient's situation, including their medical history, current condition, needs, preferences, and goals. You can use various tools and methods to gather this information, such as interviews, questionnaires, scales, tests, and observations. You should also involve the patient's family and other caregivers in the assessment process, as they can provide valuable insights and support. The assessment should be comprehensive, holistic, and patient-centered.

2 Identify the problems

The next step is to identify the main problems or issues that the patient is facing or may face in the future. These can be related to their physical, mental, emotional, social, or environmental health. You should prioritize the problems based on their urgency, severity, and impact on the patient's quality of life. You should also consider the patient's and family's perspectives and expectations, as well as their strengths and resources. You can use tools such as problem lists, problem trees, or SWOT analysis to organize and analyze the problems.

3 Set the goals

The third step is to set the goals for the care plan, which are the desired outcomes or changes that the patient and family want to achieve. The goals should be specific, measurable, achievable, relevant, and time-bound (SMART). You should also make sure that the goals are realistic, meaningful, and consistent with the patient's and family's values and preferences. You can use tools such as goal sheets, action plans, or logic models to define and document the goals.

4 Choose the interventions

The fourth step is to choose the interventions or actions that will help the patient and family reach their goals. The interventions can be medical, nursing, psychosocial, educational, or community-based. You should select the interventions based on the best available evidence, the patient's and family's needs and preferences, and the resources and constraints of the care setting. You should also involve the patient and family in the decision-making process, as well as other members of the care team. You can use tools such as care maps, care pathways, or decision aids to plan and communicate the interventions.

5 Implement the care plan

The fifth step is to implement the care plan, which means putting the interventions into practice. You should coordinate and collaborate with the patient, family, and other care providers to ensure that the care plan is followed and adapted as needed. You should also monitor and document the progress and outcomes of the care plan, as well as any challenges or changes that occur. You should use tools such as checklists, calendars, reminders, or feedback forms to facilitate and evaluate the implementation.

6 Review and revise the care plan

The sixth and final step is to review and revise the care plan regularly, based on the feedback and results of the implementation. You should involve the patient and family in the review process, as well as other care providers. You should assess whether the goals have been met, partially met, or not met, and whether the interventions have been effective, appropriate, or acceptable. You should also identify any new or emerging problems or needs, and adjust the care plan accordingly. You should use tools such as surveys, audits, or focus groups to collect and analyze the data.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?