Co-designing care plans

The Central Case Management Team had a variety of care plans being used across the team documenting Home Health Care Monitoring.

They acknowledged that their patients had little involvement in their own care planning. Therefore the team recognised the need for standardising their approach and working with patients to promote co-design. Evidence supports this approach as it is widely acknowledged that actively involving patients in their care planning improves their health outcomes.

The team aimed to put in place a new co-designed Home Health Monitoring Care Plan and achieve 100% compliance for new referrals by June 2018.

An audit tool was designed by the team to gather some baseline data relating to the current Home Health Monitoring Care Plan. (n=10)

A simple questionnaire was developed to engage patients in the process, seek feedback on the current care plan design and the appropriateness of the wording.

Initially the wording of the Home Health Monitoring Care Plans was as follows:

“To promote optimal health and reduce the risk of other health problems developing, through health education and preventative measures”

Patient Feedback included comments such as:

  • The words are too complicated
  • I don’t understand the wording
  • Can we simplify the language?

Patients decided to replace with the following:

“To check your health and keep you safe at home”

Staff worked with patients to agree a set of clinical and patient priorities.

Compliance with the completion of care plans by staff increased from 28% to 100%. Personalisation of care plans increased from 40% to 100% in the 2nd PDSA cycle.

For more detailed information about the project plan and the organisational learning that was achieved as a result, please download the team's project poster: