Document type
Patient information
Hertfordshire and West Essex ICB
Output type
Clinical Pathways

Care Planning

Care planning is a process that optimises care and enables an individual to actively participate in their health and care management. It can identify what is working well in their care, what can be improved and what can be put in place for future events. The process includes:

  • Reviewing a patient’s medical conditions and optimising care including their medications
  • Assessing the individual’s wider, holistic needs including:
    • Any issues that could adversely affect their wellbeing, such as depression, anxiety or loneliness
    • Identifying what is important to them and their goals
  • Putting in place plans for ongoing care. This includes:
    • Referrals and signposting to appropriate services (including social prescribing and services provided by the charitable and voluntary sector)
    • Providing information (e.g. living with a long term condition, resource packs for conditions such as frailty)
    • Treatment escalation plans (e.g. what to do if a condition deteriorates, admission avoidance plans and offering ‘anticipatory’ medications)
    • Advanced planning for patients nearing the end of life (e.g. discussing power of attorney/advanced directives, preferred place of care, preferred place of death, decisions on resuscitation status).

The benefits of care planning are that it can help:

  • Increase individuals’ involvement in their care
  • Increase patients’ levels of activation and ability to self-manage any long term conditions
  • Make best use of any local resources and services that are available
  • Identify any gaps in care and ensure that these are met
  • Prevent iatrogenic events such drug interactions and adverse effects of medications (e.g. medication reviews to assess for anticholinergic burden)
  • Ensure that patients receive care in line with their wishes and avoid unwarranted emergency admissions
  • Coordinate care across different health and care settings.