Care plans based on data critical to meet patients’ needs
Care plans that help patients, rather than long obtuse documents, were at the centre of a talk delivered by Dr Michal Boyd recently.
Dr Michal Boyd, who is Associate Professor Gerontology at Auckland University and a Nurse Practitioner, believes 20 page care plans don’t cater for patients, or family’s, needs. “Once written, beautiful 20 page care plans don’t often get looked at again. How do we take them, and turn them into a daily, usable thing?”
Dr Boyd has provided and researched innovative care programmes for older people since the 1990s. As part of an event to launch interRAI data visualisation, she presented to a group of nurses from residential aged care facilities, policy officers and people interested in the health of older people, at TAS.
Dr Boyd says that long term care plans ideally need to be done within three weeks of a patient’s admission, and take into account physical, psychosocial, spiritual and cultural needs.
“Care plans need to be individualised. There are certain evidence-based things we need to do, but how do we do that for an individual?”
It’s important that services work together and care plans are communicated back to the patient’s family, Dr Boyd says. “Family members aren’t going to read a 20 page document. We need to summarise and make it easy for them.”
Living documents with realistic goals
Dr Boyd would like to see care plans become living documents, which are referred to by health professionals. She says they should include realistic, achievable goals for patients, such as “Mrs Jones can walk six metres, by 15 January 2017”, rather than “Increase Mrs Jones’ movement.”
Dr Boyd also emphasised the importance of collecting information about an older person using interRAI, a comprehensive assessment tool. interRAI is used to determine the needs of older people accessing publically funded health care services, either in their own home or aged residential care.
“It isn’t just about collecting data, but thinking about what this data means for the person?”
Recording information like when a dementia patient has pneumonia, is important as it provides valuable indicators, such as the patient nearing the end of their life.
Data can also inform health professionals and researchers of things like the link between dementia and depression.
Michele McCreadie, General Manager interRAI Services, would like to see more health professionals using interRAI, especially in primary care. “It’s about making sure the information is easily accessible and understandable to the wider healthcare team,” she says.