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