How to draw up a Care Plan

8th October 2014

What is this?


Drawing up a Care Plan is really a "long range" extension of Active Planning - and particularly of the use of Active Planning and the therapeutic journey.

Creating the document

What follow are steps to support the production of a document (the "Care Plan") but of course Active Planning emphasises the importance of the process of coming to (and re-working) these plans.

Steps


1. Assessment


This involves first addressing the question of What's the problem?, to develop a mentalized understanding of the young person's predicament and relevant contextual factors across the various functional domains that interventions will be delivered (see Working in multiple domains). This requires talking with and listening to the young person, referred to in Active Planning: a core process with clients as Taking Aim.

The pre-requisite for any of this is Engagement. A Care Plan that makes no sense to the young person is not really a Care Plan.

2. Review existing plans


There may already be plans in place. Do not reinvent the wheel, but by all means take it out of the box to have a good look at it, especially if things are not going well!

If you are using a downloaded copy of this manual to record your client's notes (ICR), then you can review your Care Plans here.

Remember that if you have a new case, there is a checklist at Starting a NEW CASE - CheckLists which will help you sequence the necessary tasks.

3. Broadcast intentions, Compare Destinations, Agree Waymarks


The Care plan, like any plan, must address the problem and the overarching Formulation and Treatment Aims that have arisen from assessment, including the young person's StrengthsResiliencies and vulnerabilities.

Active Planning: a core process with clients lays out a process for developing a collaborative (ideally co-constructed) understanding of "where we are, and where we want to head towards", especially in the steps Taking Aim, Broadcasting Intentions, Comparing Destinations and Agreeing Waymarks.

A Care Plan is a more practically-oriented account of which interventions are intended to be the core of the treatment.

The Care Plan can include the fact that additional techniques and 'bursts' of other interventions, delivered Contingently according to need at the time, will play a part in maintaining momentum and engagement.

4. Using Supervisory Structures:


The keyworker makes use of the [SupervisoryStructures] available in the team to give him or her the support and scrutiny required to ensure that the foundations of this treatment plan are based on an accurate "Mentalizing stance" towards the problems:


5. For each problem:


Include the following:
  • Brief definition of the TARGET PROBLEM
  • Brief description of the WHAT the planned intervention is.
  • Define WHO is doing this.
  • Define WHEN it is aimed to have been delivered by.
  • Define what MEASURABLE outcome you hope to achieve by doing this.
    • It is important to keep such goals realistic.
    • i.e. a family intervention might be "to reduce family rows to once a week, and stop all physical aggression."

5. Plan ahead (Reviews)


Ensure that you book and update the Client Case Review - Date and Agenda so that the current Care Plan is subject to regular review.

6. Format of a Care Plan


The Care plan recording format is deliberately left somewhat open, rather than dictated by list form, to discourage form-filling by rote and to encourage creative engagement with the material available from the assessment.

Basic materials are available (see below) to help shape the relationship between problems, background (or "upstream") factors, specific triggers, and maintaining factors (see also material at StrengthsResiliencies).

The overarching aim is to reduce the tendency to shift immediately from RiskAssessment into Action (an example of Teleological thinking) but to include the process of arriving at a broader more mentalized understading, that then informs such planning.

Sample Forms:


Download from : here