Development of a Care Plan. A patient centred approach requires that patients and their clinical providers work in partnership and that patients are supported and empowered to be involved in their own care. The practical result of this is that a GP or Practice Nurse develops a Care Plan with each patient registered on the Chronic Disease Management Programme. This Care Plan will take cognizance of the clinical aspects of the patient’s condition and their own goals for what they wish to achieve. The formulation of the plan will be an opportunity to support patients in learning about their own disease, the steps they can take to improve their own self-management, and the supports which may be available to them. It will help them to increase their awareness of a deterioration of their condition, how to recognise it and how to manage and respond to it through the development and implementation of an action plan if this should occur. From the diagnosis of a chronic disease and the Registration/First Visit the Care Planning process should begin with the development of Care Plan following discussion and agreement with the patient. This Care Plan is regularly reviewed and updated to reflect the current health and wellbeing, of the patient as well as their future wishes and expectations. The HSE has developed a Care Plan Template in partnership with GPs to provide a standardised approach (Appendix A2). This will be electronically held in the GP clinical system and appropriate fields populated from the system. Nurse prompts will appear on the system. A paper updated version can be printed for the patient to be taken away after each nurse visit.
Development of a Care Plan. The PHN, in partnership with the client, PCP/plan, or other pertinent entities, shall develop a plan to address the needs identified in the assessment process to promote optimum levels of health and ensure the client is able to receive maximum benefits from medical intervention.
