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Assessing the patient's needs and planning effective care

Benjamin Ajibade

Senior Lecturer, Mental Health Nursing, Northumbria University

View articles · Email Benjamin

assessment and care planning essay

Nurses have an essential role to play in the assessment and planning of patient care. This is emphasised in the Nursing and Midwifery Council's 2018Future Nurse proficiency standards. In this article, the author discusses the importance of person-centred care in assessing needs and highlights the need for all nursing interventions to be evidence based. The topics covered include assessing people's needs, care planning, stages of care planning, benefits of care planning, models of care, care pathways, and care clustering in mental health care. The article also highlights the significance of record-keeping.

The central role of nurses in assessing patient needs and planning care is one of the core areas emphasised in Future Nurse, the Nursing and Midwifery Council's (NMC) (2018a) nursing proficiency standards. The document categorises ‘assessing needs and planning care’ as the third of seven areas of proficiency, which are grouped into ‘platforms’. Future Nurse emphasises that the delivery of person-centred care and evidence-based nursing interventions are vital components for effective patient assessment and care planning. The standards further highlight that the nurse should understand the need to assess each patient's capacity to make their own decisions and to allow them the opportunity to give and withdraw consent.

An assessment is a form of a dialogue between client and practitioner, in which they discuss the needs of the former to promote their wellbeing and what they expect to happen in their daily life ( National Institute for Health and Care Excellence (NICE), 2021 ). Nursing assessment involves collecting data from the patient and analysing the information to identify the patient's needs, which are sometimes described as problems.

The process of planning care employs different strategies to resolve the needs identified as part of an assessment. Ideally, this will include the selection of appropriate evidence-based nursing interventions. When planning care, the patient's needs and wishes should be prioritised, and the individual must be involved in the decision-making process to ensure a person-centred approach. The planned care must take into account the patient's conditions, personal attributes and choices. It is worth noting that the principles of care planning are transferable between hospital, home and care home settings.

Section 2 of the NMC Code highlights the importance of partnership working with patients to ensure the delivery of effective high-quality care and of involving them in their care, which includes empowering patients by enabling them to make their own decisions ( NMC, 2018b ). The patient should be viewed holistically, with importance placed on the physical, psychological, social and spiritual aspects of the person's life, which are inextricable.

The intrinsic factors of a patient's condition will often affect their concordance with the advice and treatment offered. Consequently, it is important to understand the reasons for non-concordance and to tailor treatments/recommendations to each individual, which will improve the quality of care delivered.

Brooker (2007) developed the acronym VIPS to address some of the confusion surrounding what should or should not be perceived as person-centred care. VIPS stresses the following:

  • V is a value base that affirms the value of each human being, irrespective of age and cognitive ability. This is the foundation for individualised care
  • I is individualised care that considers the individual's distinctiveness and holistic needs
  • P is about seeing the world from the patient's perspective, to ensure that the health professional takes the patient's point of view into account when providing care
  • S is about maintaining a social environment that supports the patient's psychological needs, including their mental, emotional and spiritual needs.

Health professionals should endeavour to involve the patient in decision-making and enable them to make choices as much as possible, using a range of approaches to achieve this ( Lloyd, 2010 ). Unless proven otherwise, a nurse must assume that a patient has the capacity to make their own decisions, in line with the Mental Capacity Act 2005.

The following draws on the author's experience in mental health nursing but can be applied to other areas of nursing care.

Care planning

Planning care is essential in the delivery of appropriate nursing care. Following assessment of a patient's needs, the next stage is to ‘plan care’ to address the actual and potential problems that have been identified. This helps to prioritise the client's needs and assists in setting person-centred goals. Planned care will change as a patient's needs change and as the nurse and/or other health professionals identify new needs. Care planning assists professionals to communicate information about the patient's care to others ( Department of Health (DH), 2013a ; NICE, 2021 ), to facilitate continuity of care. Communication may be predominantly verbal, but it will also always involve documentation in a variety of formats, including computer-based, handwritten or preprinted care plans.

It is essential for nurses to consider their consultation style when developing a care plan in order to reduce the risk of paternalism when communicating with the patient and discussing their needs. Collaborative consultation encourages patients to participate in their care and improves rapport, while a paternalistic approach will generally minimise an individual's part in, and responsibility for, their own care needs and may compromise care outcomes and concordance ( Leach, 2010 ). A collaborative/partnership consultation style facilitates a person-centred approach by the practitioners and involves the patient in their care. Such an approach can include asking questions such as: ‘We have different types of treatment approaches that could be considered, what are your preferences?’ This is in contrast to a paternalistic consultation style with the health professional announcing any decisions with a statement such as: ‘I am going to prescribe a certain treatment for you.’

When drawing up a care plan with a patient the nurse should take into account a number of considerations ( Box 1 ).

Box 1.Nursing considerations

  • The patient should know the reason for the assessment
  • The assessment should be flexible and adaptable to the needs of the individual
  • The patient must be fully involved and their dignity, independence, and interests should be paramount
  • The patient can have someone with them, if preferred
  • Appropriate language and terminologies should be used throughout the consultation
  • The diversity of the individual client, their beliefs, values, culture and their circumstances must be considered
  • It is essential to consider the patient's gender, sexuality, ethnicity, disability and religion as part of the assessment
  • Be open to listening to the patient's personal history and life story
  • The entire family's needs should be considered, inclusive of the patient and their carers: remember the importance of providing holistic care
  • Cost-effectiveness should also be taken into account

Sources: Department of Health, 2011; National Institute for Health and Care Excellence, 2021

Stages of care planning

Care planning has been described as the third stage of the nursing process ( NMC, 2018a ; Toney-Butler and Thayer, 2021 ). It includes assessing the patient's needs, identifying the problem(s), setting goals, developing evidence-based interventions and evaluating outcomes ( Matthews, 2010 ). This will require the health professional to apply high-level critical thinking, decision-making and problem-solving skills. It is important to note that a care plan can be prescriptive: it is devised after a patient has been assessed through the prescription of nursing actions ( Hogston and Simpson, 2002 ) or through collaborative working involving the multidisciplinary team.

In some situations there will be differences between what the nurse sees as a priority in terms of the patient's needs and what the patient wants. An example of this would be a patient with mental health problems who may be at high risk of self-harm, who may need to be put on intermittent 15-minute observation. In such cases, a patient would be deemed as not having capacity to make decisions and the nurse will need to use their clinical judgement to prescribe the best treatment option. The care plan can still be agreed in conjunction with the patient once the nurse has explained the reasons for the interventions and acknowledged in the care plan that this is not the patient's preferred choice.

In situations where the patient has capacity to make decisions, the care plan should be agreed in collaboration with the service user ( NHS England, 2016a ).

Identifying needs

As part of the care planning process, the nurse will identify a patient's needs/problems and propose a set of interventions to address them in order of priority, ensuring that everything is in agreement with the patient. To ensure that appropriate goals are set, a patient's needs will be classified as high, intermediate and low.

Each goal provides an indication as to the expected outcome, along with the proposed interventions required to meet the patient's problems/needs, all of which must be patient centred. It is important, in collaboration with the patient, to set both short-term, achievable goals and longer-term goals that may take days, weeks or months to accomplish. One way nurses can ensure this is to apply the SMART goal-setting approach to ensure that the goals are ( Revello and Fields, 2015 ; NurseChoice, 2018 ):

  • M easurable
  • A chievable
  • T imely (within a defined time frame).

Interventions

Interventions are nursing actions/procedures or treatments built on clinical judgement and knowledge, performed to meet the needs of patients. The actions should be evidence based and indicate who will carry them out, when and how often ( Hogston and Simpson, 2002 ). The scheduled interventions will have been agreed with the patient with the aim of improving their health condition, and each subsequent action should strive to meet the goals set at the previous stage. Brooks (2019) outlined three types of intervention:

  • Those independently initiated by nurses
  • Those that are dependent on a physician or other health professionals
  • Those that are interdependent, that is, those rely on the experience, skills and knowledge of multiple professionals.

Independent nursing interventions are planned and actioned by nurses autonomously ( NMC, 2018a ), and these actions do not require the nurse to have direction from another health professional. When actioning interventions dependent on other health professionals, the nurses must determine the appropriateness of any directions from other health professionals before carrying them out because the nurse remains accountable for the actions, for example, the administration of prescribed medication ( NMC, 2018a ). Due to developments in the nursing profession, some advanced nurse practitioners can now prescribe interventions, eg prescription of medication can be done by nurse independent prescribers or nurse supplementary prescribers ( Royal College of Nursing, 2014 ). Interdependent interventions are usually recorded in collaborative care plans reviewed in multidisciplinary (MDT) meetings and must be agreed by all parties involved. Both the goals and interventions must be communicated in a timely manner to all those involved in the patient's care.

This is the stage when a planned intervention is evaluated to assess whether or not it has been achieved. This can be an ongoing process, and the care plan should document the frequency and time frame for evaluating the intervention. If the initial goal becomes unachievable, the nurse will be required to reassess the patient's needs, and review and revise the interventions.

Benefits of care planning

The DH (2011) highlighted that the aim of care planning is to improve the quality of care and outcomes by respecting individual wishes and enabling patients to acknowledge the ownership of their condition and ensuring they have the ability to influence the outcomes. Health professionals should engage individuals in decision-making and facilitate them to take control of their health by agreeing common goals to improve outcomes. This will have additional benefits for both the patient and health services as it should reduce the number of GP appointments and emergency admissions the patient may require. Promoting self-management of long-term conditions can also help slow progression of illness.

Care planning empowers patients to care for themselves when they are self-managing their health and when they may have difficulty accessing a health professional. This became evident during the pandemic, with patients often having to go for extended periods between appointments with their health professionals. Care planning has really come into its own in community care in the past few years, which became evident during the pandemic—particularly in the field of mental health—because it leads to better patient concordance with treatment and other care needs without the need for constant input by health professionals. This benefits both health professionals and the NHS: it increases job satisfaction, brings efficiency savings and improves the quality of patient care ( DH, 2011 ).

Model of care

Models of care are used to deliver best practice in health care. An integrated services care model is multifaceted and enables the co-ordination of care by different health and social care professionals to meet individual patient needs. It encompasses patient-centred care and enables care staff across different providers to reduce duplication, confusion, delay and gaps in services ( Monitor, 2015 ). In the modern NHS, this is the preferred model of care.

The care plan is an integral part of this model because it enables the creation of shared care plans that map different care processes. It becomes a point of reference for various providers involved in the care of the patients, ensuring the co-ordination of care across services ( Curry and Ham, 2010 ; World Health Organization, 2016 ).

Care pathways

Care pathways, which are also known as critical pathways, clinical pathways, integrated care pathways, care paths and care maps, are used to describe a specific patient journey that dictates the care to be provided or process to be followed for a patient's particular condition or needs. An evidence-based care process is established for specific conditions by considering expert opinion that takes into account the evidence to recommend interventions that have been shown to achieve better health outcomes cost-effectively ( Centre for Policy on Ageing, 2014 ).

Care pathways are often developed at local level and have been shown to be efficacious at meeting local needs. They are also known to improve cross-setting collaborations. Clinical pathways are aimed at providing effective health care appropriate for the patient group of conditions, thereby reducing hospital stays, leading to cost-effective health care ( Kozier et al, 2008 ).

Care clusters

Care clustering is a needs assessment tool that is used to rate a patient's care need against specific scales:

‘A cluster is a global description of a group of people with similar characteristics as identified from a holistic assessment and then rated using the Mental Health Clustering Tool (MHCT).’

NHS England, 2016b

This framework is used to plan and organise mental health services, including the care and support provided to individuals based on their illness and individual needs. One of the care clustering tools used in the NHS is the Health of the Nations Outcome Scales (HoNOS) ( Wing et al, 1998 ; Yeomans, 2014 ; NHS England, 2016b ).

Mental health services were brought under the scope of Payment by Results (PbR) in the NHS in 2012-2013.

‘Payment by Results (PbR) is the transparent rules-based payment system in England under which commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient's healthcare needs.’

Consequently, as part of the care planning process, nurses need to take into account the cost-effectiveness of any interventions in order to consider how much funding is likely to be available for an initial completion of assessments, during scheduled reassessment and at any subsequent reassessment after a significant change in the patient's needs.

Box 2.Importance of complying with guidelines when undertaking assessment and planning care

  • You must be compliant with the Nursing and Midwifery Council (2018b ; 2021 ) guidelines for record and record-keeping
  • Adhere to the employing local organisation's policy on record-keeping, eg local trust policy
  • Follow the NHS trust Care Programme Approach (CPA) policy ( Department of Health, 2008 )
  • Collaborate with all those involved in a patient's care planning process

Importance of record-keeping

Accurate record-keeping is essential in the assessment of needs and planning care. This complies with the NMC (2018b) which states that record-keeping is fundamental to nursing practice, emphasising that records must be accurate and precise.

Health professionals should be aware of the need for legal accountability when documenting care in a written record because such records could be used in any legal proceedings ( Dimond, 2005 ). A record refers to not only a patient's record, but encompasses all records related to an individual nurse's range of practice. It is important to include the person being cared for in the record-keeping process, who should be asked to sign the plan of care, if they have capacity to do so ( NMC, 2021 ).

It is good practice to make an entry in the care documentation if a service user is unable to sign or agree to their planned care and state the reason for this ( Butterworth, 2012 ). In addition to paper-based records, care plans can be entered into the electronic health/patient record system used in the practitioner's service ( NHS website, 2019 ).

Best practice in writing care plans

There are some critical factors to consider when writing a focused person-centred care plan. One of these is to clearly document in detail the needs of the patient and to use the patient's language whenever possible, for example: ‘Mr D likes to dress smart every morning, but has been finding it difficult to make the choice of clothing to wear.’ An example of a poor way to record the same issue might be: ‘Mr D is unable to dress by himself’ and the aim is ‘Mr D will appear to dress smartly’.

The documented goal/aim of the care plan should be determined by applying the SMART acronym. It is therefore vital to ensure that the aim is specific by focusing on issues that can be measured, with goals that are achievable and realistic. It is also important to suggest and record a time frame within which a patient's short-term and long-term goals could be achieved. In relations to Mr D's clothing, a daily time frame might be appropriate. To come to an agreement over this issue, Mr D might be asked: ‘Mr D, would you like to be able to make your own choice of clothes to wear every day with the support of staff?’ The projected daily goal would then be recorded as part of the care plan documentation.

An intervention must specify how a goal/aim will be achieved, including who will be responsible for implementing each task. This could be the staff nurse on duty, team nurse, team leader, the nurse in charge and/or the patient (please put the patient's name). Evaluation should be carried out regularly and documented, and should conform with the proposed time frame outlined as part of the suggested intervention. Evaluations should be undertaken whenever actions are performed in accordance with each proposed intervention, and details of the progress of the patient's problem/needs documented.

In conclusion, the article has discussed the importance of assessing patients' needs, emphasising person-centred care using the VIPS acronym devised by Brooker (2007) . It has stressed the notion for all nursing interventions to be evidence based. The stages of care planning were discussed, and the application of the SMART goal-setting approach was highlighted. Record-keeping is an integral part of care planning in the communication of patient's care and progress. The benefits of care planning in improving quality of care and outcomes, respecting individual wishes, thereby empowering the patient was recognised.

LEARNING OUTCOMES

  • Nurses must ensure that assessment of patient needs and care planning are always focused on the person
  • All nursing interventions must be evidence based
  • The goals set out in a patient's care plan must be achievable and measurable, and should include time frames within which both short- and long-term goals can be achieved
  • Record-keeping is a vital component of care planning and is part of communicating aspects of a patient's care, and their progress towards their goals, with other health professionals involved in their care

CPD reflective questions

  • In the context of a patient's health, what should you aim to do when care planning?
  • Who should you involve in the care planning and why? Should the patient have a copy of the care plan?
  • Is it acceptable to destroy care plans or other records?
  • When should care plans be reviewed?

Assessing the patient's needs and planning effective care

Affiliation.

  • 1 Senior Lecturer, Mental Health Nursing, Northumbria University.
  • PMID: 34761986
  • DOI: 10.12968/bjon.2021.30.20.1166

Nurses have an essential role to play in the assessment and planning of patient care. This is emphasised in the Nursing and Midwifery Council's 2018 Future Nurse proficiency standards. In this article, the author discusses the importance of person-centred care in assessing needs and highlights the need for all nursing interventions to be evidence based. The topics covered include assessing people's needs, care planning, stages of care planning, benefits of care planning, models of care, care pathways, and care clustering in mental health care. The article also highlights the significance of record-keeping.

Keywords: Assessing needs; Care clustering; Care pathways; Person-centred care; Planning care.

  • Patient-Centered Care*

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Integrating Personalized Care Planning into Primary Care: a Multiple-Case Study of Early Adopting Patient-Centered Medical Homes

Rendelle e. bolton.

1 Center for Evaluating Patient-Centered Care in VA, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Memorial Veterans Hospital US Department of Veterans Affairs, 200 Springs Road, Bedford, MA 01730 USA

2 Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453 USA

Barbara G. Bokhour

3 Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA

Timothy P. Hogan

4 Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA 01605 USA

Tana M. Luger

5 Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, 650 Charles Young Dr. S. 31-269 CHS, Box 951772, Los Angeles, CA 90095-1772 USA

Mollie Ruben

6 Department of Psychology, University of Maine, 5742 Clarence Cook Little Hall, Orono, ME 04469 USA

7 Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, US Department of Veterans Affairs, 150 South Huntington Avenue, Boston, MA 02130 USA

Gemmae M. Fix

Personalized care planning is a patient-centered, whole-person approach to treatment planning. Personalized care plans improve patient outcomes and are now mandated for chronic care management reimbursement. Yet guidance on how to best implement personalized care planning in practice is limited.

We examined the adoption of personalized care planning in patient-centered medical home (PCMH) clinics to identify processes and organizational characteristics that facilitated or hindered use in routine practice.

Qualitative multiple-case study design. We conducted site visits at PCMH clinics in four US Veterans Health Administration (VHA) medical centers. Data included 10 general clinic observations, 34 direct observations of patient-provider clinical encounters, 60 key informant interviews, and a document review. Data were analyzed via qualitative content analysis using a priori and emergent coding.

Participants

Employees and patients participating in clinical encounters in PCMH clinics at four VHA medical centers.

Key Results

Each clinic used a distinct approach to personalized care planning: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. Each varied in workflow, healthcare team utilization, and degree of integration into clinical care. Across sites, critical components for implementation included expanding planning beyond initial assessment of patient priorities; framing the initiative for patients; using a team-based approach to care plan development and updates; using communication mechanisms beyond the electronic health record; and engaging stakeholders in implementation planning.

Conclusions

Personalized care planning is a novel patient-centered practice, but complicated to implement. We found variation in effective implementation and identified critical components to structuring this practice in a manner that engages patients in treatment aligned with personal priorities. Primary care practices seeking to implement personalized care planning must go beyond simply asking patients a series of questions to establish a plan. They must also engage team members in plan development, communication, and dissemination.

INTRODUCTION

Personalized care planning, a process to collaboratively develop care plans tailored to patient priorities and social contexts, is increasingly important to providing high-quality, patient-centered care. 1 – 3 Despite varying contents and terminologies (e.g., personalized care plans, comprehensive shared care plans), these approaches incorporate common elements including (a) patient-provider discussions to identify goals; (b) development of holistic plans that attend to clinical and non-clinical needs; and (c) mechanisms to share plans across providers to coordinate care. 1 Consonant with goal-directed care, these plans are designed to align healthcare with what matters most to patients, shifting away from a disease-oriented paradigm. 4 – 7 Often used with medically complex patients, personalized care plans have been effective in improving outcomes when integrated into routine care 8 and are now mandated by the Centers for Medicare and Medicaid Services for chronic care management reimbursement. 9

In 2013, the US Veterans Health Administration (VHA) initiated a version of personalized care planning known as personal health planning (PHP). Consistent with approaches described above, PHP is a mechanism to collaboratively develop care plans aligned with patients’ personal goals and social contexts. In its idealized form, PHP is a process involving assessment of patients’ priorities, shared goal identification, and services supporting goal attainment (Fig. ​ (Fig.1). 1 ). Key features include patient-centered communication, incorporation of non-clinical domains like spirituality or relationships, and care coordination across the healthcare system. 10 Adoption is underway across VHA, often in primary care clinics organized according to the patient-centered medical home (PCMH) model. 11 Given PCMH’s emphasis on whole-person care, patient-centered dialogues, and care tailored to patient preferences, these settings align well with the goals of PHP and conceptually are an ideal match for PHP implementation. 12 – 16

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Components of personal health planning. Adapted from VHA Office of Patient-Centered Care and Cultural Transformation.

Yet integrating personalized care planning into routine practice is not well understood and may present considerable challenges. 6 Unlike implementing direct-care guidelines such as disease screening or surgical checklists, PHP requires a cultural shift to shape care around patient priorities. 3 , 6 , 10 This shift is similar to the implementation of other complex initiatives including PCMH, requiring buy-in, role negotiation, coordination, and integration with clinical informatics. 17 – 23 Although research on challenges specific to personalized care planning implementation is limited, one feasibility study of PHP identified similar challenges. 10

Therefore, we sought to characterize how personalized care planning was structured and implemented early in VHA’s adoption of this practice. What organizational characteristics facilitated implementation, and which provided challenges? We examine PHP adoption in four VHA PCMH clinics to provide insights into healthcare organizations seeking to incorporate similar patient-centered care practices into routine care.

Study Design

We used a qualitative multiple-case study design 24 – 26 to examine PHP implementation in primary care at four VHA hospitals. Consistent with case study approaches, 24 , 26 we treated each site’s implementation of PHP in one PCMH clinic as a case. We use the terms case, site, and clinic interchangeably. We conducted direct observations of care and key informant interviews, and collected documents relevant to PHP to provide in-depth understanding of the organizational context and adoption approach at each site. As this project was intended to inform VHA operations on PHP implementation, the Bedford VHA Hospital Institutional Review Board designated this study quality improvement, exempting it from further oversight.

Recruitment and Participants

We selected four sites in collaboration with the national office leading PHP implementation based on program robustness, including PHP documentation in the electronic health record (EHR), programs running for at least 1 year, and PHPs conducted with a general patient population. We worked with individuals leading implementation at each site to coordinate a multi-day visit. Clinic employees and patients were invited to participate. We informed individuals that participation was voluntary, was confidential, and would not impact their employment or (for patients) their healthcare. Assent was obtained from all participants.

Data Collection

During 2–3-day site visits between April 2014 and June 2015, investigators conducted (a) general clinic observations; (b) direct observations of clinical encounters; (c) semi-structured interviews with clinic leadership, PCMH team members, other clinic staff, and patients; and (d) review of PHP-related documents. Investigators spent each site visit day in the clinics, conducting observations and inviting clinic employees and a convenience sample of patients present that day to participate in interviews. They also requested copies of PHP-related documents used in the clinic, including EHR templates, and noted posted media about PHP, photographing clinic spaces when possible. Table ​ Table1 1 describes the data collected to support each case. Observations were recorded in field notes to capture key aspects of PHP implementation, communication about PHP, and patient-provider interactions. 27 Interviews focused on experiences with PHP, adoption facilitators/barriers, integration with existing clinical practices, and the clinical team’s role in PHP.

Data Collected to Support Each Case

We conducted a directed content analysis 28 using a priori codes based on principles of patient-centered care. 29 Emergent categories captured additional content relevant to PHP adoption and processes. Six team members coded data in pairs, by site, sorting data into categories to capture relevant content. The entire team discussed coding to ensure consensus. Consistent with case study methodology, 25 , 26 we developed a synthesis for each case by reviewing individual data summaries in coding categories, using constant comparison and summarizing findings for each site. Finally, we compared case-level summaries to understand differences in implementation between sites.

We identified four distinct approaches to implementing PHP at the sites studied: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. To characterize each approach, we describe three domains that varied among the sites: clinic context, PHP workflow, and PHP integration (the extent to which PHP was incorporated into clinical care). Findings from general observations ( n = 10), direct observations of clinical encounters ( n = 34), semi-structured interviews ( n = 60), and PHP-related documents ( n = 7) are presented below. Some quotations are included to illustrate specific points. Table ​ Table2 2 provides an overview of the PHP approach at each site.

PHP Approach in Four VHA Primary Care Clinics

All four clinics were selected by site leadership to implement PHP, with discretion in how to locally operationalize the initiative. Each clinic comprised multiple PCMH teams that included a clerk, nursing assistant (NA), nurse (RN), and primary care provider (PCP). Other professionals (e.g., social workers, clinical pharmacists, nutritionists) worked across teams. All clinics retained the components of the PHP model (Fig. ​ (Fig.1) 1 ) including making referrals to known service providers within and outside of the clinic to help patients achieve selected goals. Sites relied on templated progress notes in the EHR to share PHPs. Finally, all sites received support from the national office leading PHP via monthly calls and a centralized website.

Case 1—Distributed Tasks Approach

This Southwestern PCMH clinic received national funding to promote patient-centered care initiatives including PHP. Facility leadership selected this clinic to implement PHP, perceiving this newly opened clinic as an opportunity to test new programs. Staff input on PHP adoption was incorporated through staff-wide meetings.

Patients were chosen in advance for PHP; the nurse reported that she “scrubbed” the appointment list, identifying patients she subjectively thought would be interested in or benefit from a PHP. For selected patients, PHP development was distributed across the PCMH team, engaging all members except the clerk. The nursing assistant would read questions from an EHR template to assess patient priorities and patient self-ratings of current and desired health status. The RN used patient responses documented in the EHR to collaboratively identify goals and develop an action plan. The PCP then briefly reviewed the plan with the patient and approved referrals. Plans were largely based on available VHA and community-based referral options, selected from an existing list.

Integration

PHP was well-incorporated into clinical routines, occurring alongside other tasks. For example, we observed the NA seamlessly move from history-taking and asking prevention questions (e.g., seatbelt use) into asking PHP assessment questions. However, the contrast between routine clinical versus self-reflective questions (e.g., “what brings you joy?”) were unexpected. Several patients were visibly surprised and even tearful as they self-reflected, with one patient later reporting the “personal (questions)…caught me off guard.”

Despite PHP incorporation into clinical routines, we observed care to be minimally organized around patient priorities, including a fixed approach for referrals to address selected goals. For example, all patients observed were referred to a weight loss program, despite only one specifying weight management as his goal. Although PCPs reviewed plans and approved referrals, we observed few conversations with patients about their priorities. Similarly, despite multiple team members engaged in PHP development, we observed minimal communication about PHP among team members. Staff described limited communication with services to which patients had been referred, hindering knowledge of whether patients were receiving adequate support to reach goals. Finally, while posters with PHP-related information were ubiquitous, patients reported unfamiliarity with the initiative.

Case 2—Two-Tiered Approach

This recently redesigned PCMH clinic in a large Northeastern hospital also received national funding to promote patient-centered care. In addition to common PCMH staff, this site employed a health coach to support patients. 30 , 31 Hospital leadership selected this clinic for PHP as part of its cultural transformation to emphasize wellness. Leadership provided organizational supports including policies to ease providers’ administrative responsibilities. Staff received mentoring in patient-centered communication, including PHP, during a weekly half-day in-service.

PHP occurred through a two-tiered approach. First, PCPs would routinely ask all patients three questions to assess patient priorities, gauge patient perceptions of health, and explore interest in health coaching. The health coach would then work with interested patients to develop a PHP. She oriented patients to this process by describing it as “identify(ing) hurdles to help you be your best self.” Once completed, the health coach would provide ongoing support, refer patients for services, and regularly check-in. She characterized her work as the “umbrella” under which patients’ needs were addressed.

We observed that most PCPs incorporated the three questions into clinical encounters but varied in their comfort initiating these conversations. Sometimes the questions were “tacked on” at the end of the encounter, visibly confusing patients who felt they had already expressed their concerns (e.g., pain management). Care was variably tailored to patient priorities: in our observations, some providers and the health coach exemplified patient-centered interactions; others retained provider-driven approaches. Within-team communication about PHP was limited. While problem-solving around general PHP use was explored during weekly in-services, participants reported rarely discussing individual PHPs during smaller team huddles. The health coach shared PHPs with referral services via phone and EHR to coordinate care.

Case 3—Health Coaching Approach

Like site 2, this large Midwestern PCMH clinic employed a health coach. It additionally utilized RN care managers to provide chronic disease management services. The impetus for PHP arose from a regional effort to promote relationship-based care, a model that emphasizes patient-centered communication and patient-provider relationships. 32 A nurse executive led PHP adoption, working closely with the health coach.

PCPs identified patients with chronic conditions whom they felt would benefit from PHP. Receptive patients were referred to the health coach, who developed PHPs. He also provided ongoing support to facilitate goal achievement and linked patients with clinical and non-clinical services. RN care managers from two PCMH teams partnered closely with the health coach to develop PHPs for shared patients.

PHP was fully incorporated into the health coach’s work and PHP posters were hung by his office. While the RN care managers routinely aligned their care with patients’ PHPs, we observed little evidence of integration elsewhere. The health coach was primarily responsible for PHP, with staff members noting that PHP would likely end if he left. Communication was limited, with the health coach reporting rare opportunities to share PHPs with PCMH team members. He felt regularly excluded from huddles due to a lack of recognition of his value as a paraprofessional, describing himself as “gum on the bottom of a shoe” in the eyes of most of PCPs.

We also found varied awareness of PHP among providers to whom patients were referred. For example, a social worker was unfamiliar with PHP. Others with familiarity reported rarely aligning care with PHPs. For example, a clinical pharmacist described looking for PHPs only in “cricket situations” when patients didn’t “volunteer” information. Instead, providers to whom patients were referred developed provider-driven care plans in accordance with their scopes of practice: “[My] plan has more to do with the goals that we actually set for the patients... [We] make sure that they’re onboard…I mean I’m never going to tell a patient, ‘You need to do this,’ without them…acquiescing” (nutritionist).

Case 4—Leveraging a Village Approach

This semi-rural Pacific Northwest PCMH clinic shared space with mental health and nutrition services, facilitating awareness of PHP. Efforts were underway to have clerks who traditionally filled clerical roles be involved in PHP, even training them as paraprofessional health coaches. PHP was blended with other health promotion activities, and adoption was led by a nurse executive and health promotion program manager. Staff described involvement in adoption planning to make the process “patient-friendly.”

PHP was facilitated through a standardized form probing patient priorities and interest in existing referral options. Clerks introduced the concept and patients completed the form independently preceding the visit. Staff then reviewed the form with the patient during the encounter, initiating referrals based on the patient’s responses. Upon check-out, the clerk revisited the plan developed to ensure patient understanding and awareness of referrals. The RN later called patients to discuss their PHP.

Clerks introduced PHP to patients as a new way of practicing healthcare, framing PHP as a shift to patient-driven care, where “if we know what matters most to you, then we can make it what matters most to us too.” While PCPs reported using the form in clinical encounters, our observations revealed inconsistencies: not all providers viewed the form or used it in treatment planning. Further, the list of referral options was not always responsive to patients: we observed some patients decline PHP due to lack of interest in available services.

Communication about established PHPs varied. Clerks and the RN reviewed progress with patients, yet PHP was largely absent from patient-PCP discussions and team huddles. The clinic’s medical director did not view PHPs in the EHR, expressing uncertainty about where to look. Unlike other clinics, referral providers were familiar with PHP and used it to guide care. For example, a mental health practitioner described reviewing PHPs to orient herself to patients’ goals, social context, and interests, allowing her to align treatment.

Themes Across Cases

Although sites differed in their approach to PHP, we identified five overarching areas for facilitating implementation: using an iterative approach; framing the PHP; using a team-based approach; communicating beyond the EHR; and team engagement in implementation planning.

Using an Iterative Approach

When sites used PHP as an iterative process, they achieved better incorporation of patient goals in care planning. We found that sites 2 and 3 achieved richer PHP integration through their respective approaches, where plans were developed and revised as patients’ lives evolved. An embedded health coach followed patients and provided ongoing support to achieve goals. Alternatively, sites 1 and 4 treated PHP development like other clinical tasks, lacked follow-up on patient goals, and based plans on pre-identified referral options.

Framing the PHP

Sites that framed PHP better oriented patients to its purpose and engaged them at the start. At site 4, clerks described PHP to patients upon giving them the PHP form in advance of their appointment, while health coaches at sites 2 and 3 spent time introducing patients to the concept of PHP and health coaching services. In contrast, when framing was absent, patients struggled to respond to PHP questions or identify personal priorities and goals. At site 2, in the absence of the health coach, we observed a provider asked the “what really matters” question at the end of the clinical encounter. This resulted in confusion for the patient who replied that his previously discussed pain was what mattered. A similar pattern was found at site 1, where patient confusion and distress were observed when PHP questions were asked without adequate framing.

Using a Team-Based Approach

We identified two disparate styles to PHP development in the context of team-based care: spreading responsibility across team members (sites 1 and 4) versus reliance on health coaches (sites 2 and 3). When PHP was not addressed by all team members (sites 2 and 3), we found that clinical conversations by uninvolved healthcare workers failed to acknowledge and align treatment with patient priorities. Alternatively, at site 3, where RN care managers were included in PHP conversations, we observed strong alignment between care and patient priorities. Simultaneously, at this same site, the failure of the nutritionist and clinical pharmacist to utilize PHPs to guide care planning resulted in unaligned, provider-driven treatment.

Communicating Beyond the EHR

We found important communication gaps at all sites despite consistent EHR documentation. Across all sites, the EHR was the primary communication mechanism, yet alone was insufficient. Discussions about patients’ PHPs were excluded from huddles, team meetings, and other routine team communications at all sites, unless informally initiated by the person charged with leading PHP. Subsequently, not all team members were familiar with patient goals or developed plans. At site 3, PCPs were unfamiliar with the process, which they perceived as the responsibility of the health coach; at site 4, not all PCPs were aware they could view the PHP in the EHR.

Team Engagement for Implementation

Most sites engaged clinic staff in PHP design, facilitating its awareness and use. This was accomplished through half-day planning retreats, periodic staff meetings to review adoption challenges, and incorporation of ideas across all staff members (e.g., patient-friendly edits to the form used at site 4). Notably, however, PCPs across most sites were minimally engaged with implementation planning, resulting in less PHP familiarity and use.

We found substantial variation in PHP implementation in four VHA PCMH clinics, including variation in workflow, ownership and delegation, staff engagement, and utilization. Like PCMH reorganization, 13 PHP was envisioned as a way to transform treatment planning. The approaches taken by the sites studied achieved varying degrees of success incorporating PHP into clinical routines, organizing care around patient priorities, and communicating about PHP. Even the early adopting sites with robust PHP practices profiled in our study faced challenges. Our findings provide several important insights into future adoption of personalized care planning programs like PHP.

Personalized care planning is more than a set of questions for patients to answer. It is a process to orient care around patient priorities, with follow-up conversations enabling plan revisions responsive to patients’ evolving lives. 1 , 2 , 10 Sites in our study variably achieved this spirit, with two sites accomplishing this goal via ongoing health coaching. The remaining sites approached PHP as a box to be checked, which did not always align with patient priorities. As we have described elsewhere, 6 , 33 in the absence of broader efforts to transform culture, care planning initiatives like PHP are at risk of being implemented in a manner similar to other quality improvement tools such as clinical reminders or checklists. Our case study findings substantiate this argument. As primary care clinics adopt personalized care planning initiatives, conceptualizing planning as an iterative process that routinely engages patients in conversations about what really matters better aligns care with patients’ needs. Some sites in our study subjectively selected patients perceived to be good candidates for PHP, perhaps due to limited time and resources. In an ideal world, all patients would have the opportunity to explore and share their health goals with providers, ensuring care that considers patients’ life contexts. 7 , 34 However, in contexts with limited resources, focusing PHP on patients with complex chronic conditions may be warranted.

Patient-centered care initiatives, like PHP, are distinctly different from other disease-centric programs. They necessitate different patient-provider interactions, recognizing patients as experts in their own lives and collaboratively engaging stakeholders, including patients and care team members alike, as partners. 5 This may be very different for patients who are used to traditional, prescriptive care. Indeed, in our study, we found that patients were unaccustomed to this approach; lack of framing resulted in confusion and distress. Future PHP adoption efforts should attend to framing as a key component. Using clerks to introduce PHP, as one site in our study did, may help orient patients and unburden busy providers while achieving a key PCMH goal of optimizing staffs’ responsibilities. 35

We found that PHP adoption required an integrated, team-based approach consistent with the PCMH model 36 , 37 for its successful incorporation into clinical care. Sites in our study took two overarching approaches to incorporating PHP in teams: one spread responsibility; the other centralized responsibility among health coaches. While spreading responsibility better engages all team members, it requires role shifts and communication to become fully integrated into care. This was difficult for the clinics in our study to achieve in practice. Alternatively, while placing responsibility on a single team member (e.g., health coach) created deeper collaboration with patients and facilitated patient goal–directed care, it failed to adequately engage the full team, particularly PCPs. With core principles of team-based care comprising mutual goals, role clarity, trust, and communication, 22 , 37 future implementation should carefully consider team-based approaches to develop and disseminate plans that engage but not overburden already busy members by identifying a PHP lead or point person within the team.

Communication is critical for coordination across healthcare systems, and informatics applications increasingly play a role in such efforts. 38 The EHR is necessary to enable asynchronous coordination around personalized care plans. 1 , 2 However, in our study, clinics’ reliance on the EHR was insufficient to share PHPs across the team and coordinate care around patient priorities. Developing EHR mechanisms that better represent complex evolving patient goals and readily display this information is needed for successful PHP implementation. Moreover, if PHP is to truly become a living document that originates in primary care and is brought forward through all aspects of care, then healthcare systems must incorporate additional communication mechanisms to ensure shared awareness of patient goals. Incorporating discussions of PHP into team huddles may be one strategy to facilitate better communication. 19 , 39

Successful implementation of new practices requires buy-in among those tasked with delivery. When stakeholders are engaged in the design of new practice innovations, they may be more likely to adopt them. 40 , 41 In our study, engaging clinic staff was critical to PHP implementation. Yet sites struggled to adequately engage PCPs in the PHP process, mirroring research on how demands faced by PCPs may limit engagement in transformational initiatives. 13 , 22 , 39 , 42 This raises important questions for future research regarding the role of PCPs as team leaders in PCMH and related distribution of work when implementing PHP. Further, when providers both in and outside of the clinic have limited knowledge of PHP, patients may receive mixed messages about treatment priorities. Clinics seeking to implement initiatives like PHP should engage stakeholders early and continue to promote PHP once implemented.

LIMITATIONS

This study examined PHP adoption in only four VHA PCMH clinics, all utilizing different approaches to PHP. There are likely additional approaches to PHP implementation not captured in our study. Transferability of our findings to other sites will depend in part on similarities with the sites we describe here. Future research should examine personalized care planning adoption in other healthcare organizations, expand studies to include additional aspects of implementation such as cost, and test how variation in implementation relates to patient and organizational outcomes.

Personalized care planning has the potential to transform how healthcare is delivered, intimately engaging patients in their treatment and aligning care with their priorities. Yet providers are unlikely to be successful implementing personalized care planning on their own without broader infrastructure and cultural transformation initiatives to support its integration into care. As healthcare organizations continue to adopt these practices, attention must be given to planning as an ongoing process and framing this new approach for patients and providers alike. Implementation should include the healthcare team in program design, and thoughtfully engage them in the development, communication, and dissemination of personalized care plans. While embedding plans in the EHR is necessary, it is not enough to promote shared understanding and system-level coordination aligned with patient goals. Establishing patient and team-centered communication mechanisms will be critical to truly implementing personalized care plans as a patient-centered innovation in practice.

Acknowledgments

Thank you to Jeffrey Solomon, PhD, for his assistance with data collection; Therasia Roland, MSW, for her assistance with data coding; and Juliet Wu, BS, for her assistance with manuscript preparation.

Funding Information

This study was funded by the US Department of Veterans Affairs, Office of Patient-Centered Care and Cultural Transformation, and the Quality Enhancement Research Initiative (grant no. PCE13-001). Dr. Fix is a VA HSR&D Career Development awardee at the Bedford VA (CDA no. 14-156).

Compliance with Ethical Standards

As this project was intended to inform VHA operations on PHP implementation, the Bedford VHA Hospital Institutional Review Board designated this study quality improvement, exempting it from further oversight. Verbal assent was obtained from all participants.

The authors declare that they do not have a conflict of interest.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.

Prior Presentations

This paper has not previously been presented.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Issue Cover

Article Contents

Overview of person-centered assessment, recommendations for assessment and care planning, assessment process, assessment content, assessment of the experience of the person/care partner, health status and risk reduction, turning assessment into action, conflict of interest.

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Person-Centered Assessment and Care Planning

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Sheila L Molony, Ann Kolanowski, Kimberly Van Haitsma, Kate E Rooney, Person-Centered Assessment and Care Planning, The Gerontologist , Volume 58, Issue suppl_1, February 2018, Pages S32–S47, https://doi.org/10.1093/geront/gnx173

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The quality of dementia care rendered to individuals and families is contingent upon the quality of assessment and care planning, and the degree to which those processes are person-centered. This paper provides recommendations for assessment and care planning derived from a review of the research literature. These guidelines build upon previous recommendations published by the Alzheimer’s Association, and apply to all settings, types, and stages of dementia. The target audience for these guidelines includes professionals, paraprofessionals, and direct care workers, depending on their scope of practice and training.

This paper provides practice-oriented guidelines for person-centered assessment of persons living with dementia, their family members, and care partners. It is one in a series of articles in this supplement issue and is intended to complement these other papers by building on the definition of person-centeredness provided by Fazio, Pace, Flinner, and Kallmeyer (2018) and providing recommendations for assessments that support the practices described in the subsequent papers.

Part one of this paper begins with the core concepts of person-centeredness informed by the philosophies of Kitwood (1997) and Brooker (2005) . Two additional approaches are then introduced to provide a clear philosophical and practical foundation for comprehensive, person-centered assessment: Mast’s (2011) approach to whole person assessment and Molony’s (2010) work on at-homeness. These perspectives view assessment as an ongoing, dynamic approach to care.

Part two of this paper provides recommendations for assessment based on a review of literature published since the 2009 Alzheimer’s Association (Alz Assoc). Recommendations for assessment and care planning are supported by national and international dementia care guidelines; published quality indicators; literature related to the process and/or outcomes of person-centered care; literature written by persons living with dementia and care partners; and literature published in core journals relating to specific domains of dementia assessment.

Part three discusses the evidence-based recommendations for care planning and transforming assessment data into action. Taken together, the assessment guidelines in this paper provide a foundation for the interventions described in the subsequent papers in this supplement issue.

In his seminal work on dementia, Kitwood (1997) highlights three core elements of personhood: relationship, uniqueness and embodiment. According to Kitwood, relationship implies recognition, trust, and respect, and prioritizes the experience of the person. Kitwood references Martin Buber’s concept of I-Thou relationships to convey true meetings with another in a spirit of openness, full acceptance, presence, and sense of new possibility. Kitwood (1997) points out that unfortunately:

…a man or woman could be given the most accurate diagnosis, subjected to the most thorough assessment, provided with a highly detailed care plan and given a place in the most pleasant surroundings – without any meeting of the I-Thou kind ever having taken place”(p. 12).

This statement highlights the fact that assessment and care planning are processes that are informed not only by published research and clinical expertise, but also by the possibilities that emerge in the moment , during authentic human encounters with individuals living with dementia and their families. Person-centered assessment must therefore incorporate openness to the experience and relationship unfolding in the present moment. The word assessment often conveys a goal-oriented, task-centric set of activities, but in a person-centered context, assessment begins with valuing the experience of being present with another human being, trying to understand that person’s experience, and coming to know the uniqueness of the person.

The purpose of assessment and care planning is to support the individual and family to live the best possible life, with dementia. The key components of person-centered dementia care described by Fazio and colleagues in this issue (p. 10) correspond to assessment modalities. Personhood and relationship-based care align with assessment approaches that convey respect and seek to understand the subjective experience of the individual living with dementia. I ndividualized care and meaningful engagement is practiced during assessment by prioritizing information about individual preferences, needs, values, routines, sources of joy and personal meaning. Relationship-based care and positive social environments are supported by identifying care partners and assessing their needs for support, information and resources. In residential care settings, this includes assessing staff needs, resources, satisfaction, and person-centered communication skills.

Mast (2011) describes an approach to whole person dementia assessment that combines nomothetic and idiographic perspectives. Nomothetic approaches utilize empirical studies with groups of people living with dementia to identify general principles and evidence-based strategies that may apply broadly to other persons in similar situations. The assessment recommendations found in the research literature and reviewed in this paper typify the nomothetic approach. Idiographic approaches rely on in-depth assessment of the individual in the context of his/her experiential, autobiographical and social world. Using this approach, assessment includes gathering information about life history; accomplishments, losses, significant experiences, hopes, dreams, preferences, important roles, and ways of dealing with previous challenges or stressful situations ( Mast, 2011 ). The assessment also includes information about the significant people in the person’s life, including the primary care partner and others. Mast points out that this information may not be obtained in one sitting, but is gathered across multiple encounters over time. In order to make the information useful for planning care, it must be documented, shared with other care providers, and periodically revisited and updated.

Molony (2010) conducted a metasynthesis of studies on the meaning of home that included papers focusing specifically on persons living with dementia ( Wiersma, 2008 ; Zingmark, Norberg, & Sandman, 1993 , as cited by Molony, 2010 ). Molony describes home as an experiential place of empowerment, refuge (comfort, warmth, and ontological safety), lived relationship (with persons, animals, meaningful places, cherished possessions, time, and ideas), and self-reconciliation (maintaining selfhood in the context of transition or loss). Understanding and assessing personalized meanings of home, and the processes by which home is experienced, built, shared, sustained, or lost, extends the concept of person-centered care more broadly into physical, social, and environmental domains. At-homeness is potentially threatened by medical crises and thus Kitwood’s focus on embodiment, Molony’s discussion of the lived body and traditional medical approaches to health and physical assessment are consistent with person-centered assessment.

Taken together, the core components of person-centered care as informed by Kitwood, Brooker, Fazio et al., Mast and Molony, call for an intentional preassessment phase to prepare the assessor to enter the experience of the person living with dementia and their care partner(s) by asking three self-reflective questions: (a) How will I demonstrate empathy and respect this person’s uniqueness and wholeness while inquiring about the challenges of the disease/diagnosis? (b) How will I demonstrate that I value therapeutic alliance and partnership with this person and care partner(s)? (c) How will I demonstrate therapeutic optimism (for quality of living, if not for cure) and foster hope?

Qualitative studies examining the experience of persons living with dementia draw attention to the role of the care provider’s attitude in shaping the person’s outlook on dementia ( Frank & Forbes, 2017 ). Simple strategies of therapeutic communication should not be undervalued in the assessment process. It is important to recognize that internalized stigma or therapeutic pessimism may adversely affect assessment process and outcomes ( Wolverson, Clarke, & Moniz-Cook, 2016 ).

A review of practice guidelines published after 2009 was conducted to update evidence-based recommendations related to assessment content, frequency, methods, measures, and outcomes. Wiener, Gould, Shuman, Kaur, and Ignaczak (2016) conducted a detailed analysis of 37 practice guidelines that included medical and psychiatric guidelines from diverse national and international sources including the American Medical Directors Association, the American Psychiatric Association, the American Psychological Association, the British Columbia Ministry of Health, the European Federation of Neurological Sciences and many others. Global reviews and panel summaries such as those by Callahan et al. (2014) and Mitchell and Coleman (2015) as cited by Wiener et al. (2016) were also reviewed. Some of these guidelines were setting-specific, discipline-specific, or domain-specific. Six primary assessment domains were uniformly identified as essential to assessment: cognitive status, functional abilities, behavioral symptoms, medical status, living environment, and safety. There is consensus in the literature that dementia must be distinguished from delirium and depression, and that reliable and valid instruments must be used that are designed to detect changes in cognition, function and behavior. Many guidelines recommend integrating systematic pain assessment tools that are appropriate for seniors and/or persons living with dementia. Wiener and colleagues (2016) also recommend assessment for indicators of abuse, neglect or inability to live alone including repeated hospitalizations, medication misuse, malnutrition, wandering from home. Recommendations specific to home and community settings highlight the need to assess caregiver health and signs of strain or stress, and to identify family member needs for education, support and services.

Guidelines for frequency of assessment are based on setting, with primary care assessment recommended at a minimum every 6–12 months and more often if changes in behavior, cognition, or function occur. Frequency of assessment in residential long-term care is guided by regulation, including key times such as: upon admission, after return from a hospital stay, and with significant changes in condition, function or behavior. Direct caregivers provide important assessment data in these settings, in addition to professional assessments using the MDS 3.0. All evidence-based guidelines stress the need for ad hoc assessment whenever behavioral changes occur, including an in-depth investigation of antecedents and contributors to behavioral and psychological symptoms of dementia (BPSD). Behavioral changes necessitate inquiry into unmet needs, stressors in the physical and social environment (including loneliness, boredom and isolation), and most importantly, underlying physical or psychiatric comorbidities. In these scenarios, referral to a health professional for comprehensive health assessment is recommended ( Wiener et al. 2016 ).

A few of the guidelines reviewed by Wiener and colleagues (2016) recommend system-level incentives and supports needed to promote documentation and tracking of cognition, function and symptoms, provide training for caregivers, and establish standardized protocols for pain assessment and management. In acute care settings, the National Institute for Health and Clinical Excellence (2007), as cited by Wiener and colleagues (2016) recommend referral to a liaison service that specializes in assessment and treatment of dementia.

Ngo and Holroyd-Leduc (2015) conducted a systematic review of 39 practice guidelines published from 2008 to 2013. There is significant overlap with the recommendations provided by Wiener et al., with increased emphasis on regular, serial assessment of activities of activities of daily living and cognition to evaluate and document changes over time. Serial assessment for BPSD is recommended every 3 months, and medication changes, adherence and effects are to be assessed during every visit. Assessment for vascular risk factors is also recommended.

Additional published guidelines were obtained through the AHRQ and ClinicalKey databases. Multiple authors suggest that care plans should incorporate individual values, cultures, and needs, and should promote the maintenance of function and independence to the greatest degree possible. Specific assessment domains not already highlighted include the living environment, physical exercise, recreational activities, signs of abuse or neglect, caregiver needs, advanced directives, decision making, and plans for end-of-life care. While it is beyond the scope of this review to provide detailed recommendations for each of these facets of assessment, guidance is available for individualized assessment and management related to bathing, driving, mealtime difficulties, oral hygiene, nursing care (all settings), and care planning ( National Guideline Clearinghouse, 2013 ; Clinical Key, 2017 ). The Gerontological Society of America (GSA) recently published a guideline outlining a four-step process for earlier detection and diagnosis called the KAER toolkit ( GSA, 2017 ). The toolkit is primarily intended for primary care providers, but the associated appendices and tools provide efficient, valid, recommended tools for professional assessment in multiple settings.

Callahan and colleagues (2014) reviewed evidence-based models of dementia care and identified key components for assessment and care planning. Assessment domains not already highlighted include goals of care, driving, home safety, and use of substances. The review also highlights the importance of using each assessment opportunity to evaluate the outcomes of previous therapeutic interventions. The authors recommend consideration of referral to a specialty memory care practice for ongoing evaluation and management. Additional recommendations include educating the individual and family about diagnosis, care options, and community resources. This implies that pre-existing knowledge has been assessed.

Two performance measure sets for dementia care were included in this review. The American Academy of Neurology (AAN), American Geriatrics Society (AGS), American Medical Directors Association (AMDA), American Psychiatric Association (APA), and Physician Consortium for Performance Improvement® (PCPI™) published quality measures to improve outcomes for persons with dementia (AMA, 2011). The International Consortium for Health Outcomes Measurement (ICHOM, 2017) brought together patient representatives, clinician leaders and registry leaders from all over the world to identify a comprehensive set of outcomes and case-mix variables for all providers to track. These standards are applicable to all types and stages of dementia. Table 1 depicts a comparison of the domains and topics recommended in these documents. These sources provide strong support for regular comprehensive assessment, with an emphasis on health, function, clinical, caregiver and safety domains. While there is some focus on the person living with dementia and care partner, the experience of the person living with dementia has not been a central focus in most research-based guidelines and quality measures.

Assessment Data Needed to Support Quality Measures a

Note : BMI = Body mass index; ICHOM = International Consortium for Health Outcomes Measurement; PCPI = Physician Consortium for Performance Improvement.

a Assessed annually unless otherwise stated.

To provide additional data for this review, evidence from individual research studies was gathered by searching in PubMed, CINAHL, SocINDEX, PsychINFO, and Social Work Abstracts for articles published since 2000, using various combinations of search terms including: dementia, assessment, whole person, strengths, strengths-based, needs assessment, person-centered or person centred care, nutrition assessment, symptom assessment, risk assessment, health assessment, health impact, quality of life, self-assessment, and geriatric assessment. This search yielded additional search terms that were then included in a PubMed search. After eliminating duplicates, non-English language papers and articles that were not research-based, a total 885 abstracts were reviewed. Since the goal of this paper was not to conduct a systematic review, the 108 papers selected for full text review and data extraction were prioritized based on the quantity and quality of evidence that included person-centered care or quality of life and/or experiential data from persons living with dementia or care partners, and/or publication in a core clinical, nursing or gerontological journal. Research-based articles were also included that provided elaboration of assessment recommendations given less detail in other works.

This scoping search revealed that BPSD, pain, quality of life, safety, and risk are more frequent topics for study in the professional literature than the process or outcomes of person-centered assessment and care. The search for evidence was therefore extended to include texts and audiovisual media written or hosted by persons/families living with dementia. These sources provided insight into the process of assessment and underscored the importance of supporting dignity, autonomy and the voice of the person living with dementia. A synthesis of key assessment topics is provided in Table 2 , and a summary of updated recommendations for assessment and care planning are included at the end of this paper.

Comprehensive Person-Centered Assessment

Feasibility and Scope

Regular, comprehensive assessment is recommended at baseline and interim reassessments are recommended in all settings at least every 6 months ( Wiener et al., 2016 ). Time-pressed clinical environments require prioritization and the use of toolkits to increase efficiency. The first priority is to detect issues that detract from quality of life or prevent the person from living fully with dementia. This includes detection of hidden medical illness or pain or sources of excess disability and assessment of the degree of engagement in enjoyable activities. The presence of caregiver challenges should also be assessed as these may increase risk for institutionalization. More frequent reassessment is indicated in the context of recent medication changes, changes in health or behavior, living alone, driving, unstable or multiple comorbid conditions, bothersome symptoms, care partner stress, individual or care partner health concerns, recent hospitalization, or emergency department visits ( Kales, Gitlin, & Lyketsos, 2014 ). There is considerable variability in cognitive and physical function in persons with Alzheimer’s disease and other forms of dementia have different patterns of progression that would warrant more frequent assessment. The care partner’s wellbeing and ability to provide support commensurate with the person’s needs, may also change over time. A person-centered approach will tailor the frequency of assessment to the individual and family situation.

Persons living with dementia may become fatigued by cognitive and functional demands throughout the day and experts, including persons living with dementia, recommend that when possible, assessments be conducted during times of day when the person is at peak performance, in an environment free from distractions and competing demands.

Sources of Information

Sources of information for the assessment include interviews with the person living with dementia, interviews with the care partner (and/or health care proxy if applicable), clinical records, prior assessments and observations. Observation, functional measurement and physical assessment provide objective data. The perspective of the person living with dementia should be prioritized in all assessments ( de Medeiros & Doyle, 2013 ). Individuals living with dementia often report being ignored or infantilized ( Bryden, 2016 ; Ellenbogen, 2012 ; Specht, Taylor, & Bossen, 2009 ). Using a life review approach, and asking about strengths and abilities before focusing on losses and disabilities, recognizes the person as someone who is a whole person. This forms a basis for a therapeutic partnership between the professional and the person living with dementia ( Mast, 2011 ). Research has shown that even in late stages of dementia when people tend to “live in the moment,” responses to simple questions about their well-being and feelings are possible ( Kolanowski, Litaker, Catalano, Higgins, & Heineken, 2002 ). When the caregiver or other person is serving as a health care proxy, the viewpoint of the person living with dementia should still be sought, and preferences noted, including those expressed through verbal and nonverbal means ( Bangerter, Abbott, Heid, Klumpp, & Van Haitsma, 2016 ). Repeat observations over time and/or behavior and symptom diaries are particularly useful for this purpose.

The majority of nonpharmacological treatments and care practices that have demonstrated efficacy in randomized controlled trials have targeted the person/care partner dyad and/or family caregivers ( Maslow, 2012 ). It is therefore essential that family members also be included in the assessment process. In residential or institutional settings, direct caregivers who spend a great deal of time with the person are essential informants to collect data about usual routines, preferences, sources of joy, and sources of discomfort or frustration. Caution should be used when relying exclusively on proxy report (family or staff) for subjective experiences such as pain or quality of life, which covary with caregiver variables and may not always agree with ratings from the person living with dementia ( Conde-Sala et al., 2013 ; Herr, Coyne, McCaffery, Manworren, & Merkel, 2011 ). Reliable and valid observational measures and consultation with multiple informants may be of greatest benefit in these situations.

Preparation for the Assessment

Comprehensive assessment is supported by having reliable and valid assessment instruments (e.g., the Montreal Cognitive Assessment, the Neuropsychiatric Inventory), algorithms and toolkits (e.g., Medicare Annual Wellness Visit Algorithm and Toolkit for Assessment of Cognition; Cordell et al., 2013 , KAER Toolkit; GSA, 2017 ), and resources regarding issues of frequent concern (e.g., Alzheimer’s Association materials regarding wandering and driving safety). Print and on-line resources assist the individual and family in understanding the disease, planning for the future, dealing with situational challenges, anticipating and mitigating risks, enhancing meaningful engagement, and promoting healthful practices. Table 3 contains links to resources that support person-centered assessment.

Resources for Person-Centered Assessment

The goal of systematic assessment is to identify opportunities to support personhood, reduce health risks, optimize function, and identify comorbidities that may be impacting health, function and quality of life. Priority assessment topics that support positive person-centered care include factors that are relevant to living well with dementia, such as maintaining a sense of identity, agency, belonging, purpose, and positive emotional expression ( Wolverson et al., 2016 ). This would include asking explicit questions about sources of joy, personally meaningful experiences of at-homeness and exploring the activities, environments, care practices and relationships that support the person’s strengths and/or minimize distress.

Living with dementia is dynamic and situational and therefore what “matters” at any particular time in the course of the person’s experience will change as the disease progresses, the person’s perspective changes, and challenges occur that may threaten equilibrium and/or provide opportunities for growth ( Taylor, 2007 ). The person living with dementia and care partners exist in a world of shifting salience where some things show up in the foreground as more important at a given time, and other things take the background. This means that person-centered assessment and care planning is an ongoing process, and not a one-time, finite task. A focus on the experience of the person will also guide setting-specific differences in assessment. The experience of living in the community poses challenges to autonomy, self-care, instrumental activities of daily living, and positive engagement with the social world. The experience of the person/care-partner dyad is particularly salient in this setting. This calls for proactive, systematic assessment from home, and community-based service providers. The experience of discomfort or disability related to undetected or undertreated physical and mental health conditions calls for the use of high-quality relational skills, listening, and strategic use of screening tools to identify these issues in primary care settings. In residential long-term care settings, the experience of the person living with dementia is often overwhelmed by organizational, staff, regulatory, and task-driven processes. In order to prioritize experiential assessment in these settings, leadership practices, organizational policies, culture building efforts, person-centered assessment tools, staff development activities, and quality improvement processes must all be aligned with the philosophy, goals, and practices described later in this paper.

Strengths and Facilitators of Wellbeing

In routine assessment, it is preferable to inquire about strengths, abilities, and successful self-care and caregiving approaches prior to assessing deficits and/or inquiring about alterations in personality, cognition or behavior ( Judge, Yarry, & Orsulic-Jeras, 2010 ; Specht et al., 2009 ). While periodic symptom and behavioral inventories are useful to identify triggers for more in-depth assessment and care planning, they may also foster internalized stigma and fear. Using an assessment approach that focuses on the individual’s experience conveys that the person living with dementia and their family are partners whose input is solicited, valued, and used in the plan of care.

Assessment of psychosocial and emotional health includes inquiry into overall positive and negative mood and affect, preferences for daily activities, pleasant events, quantity of social interactions, and the quality of relationships with significant people and animals ( Mast, 2011 ). Assessment tools such as the Preferences for Everyday Living Inventory (PELI) ( Van Haitsma et al., 2013 ) and the Pleasant Events Schedule ( Logsdon & Teri, 1997 ) may be used to identify opportunities to enhance autonomy, meaningful engagement and psychosocial wellbeing. Persons living with dementia share the needs of all people to express emotions, fears and opinions, play or have fun, satisfy curiosity, give and receive affection, feel a sense of accomplishment, and engage in spiritually meaningful and faith-based activities. Wolverson and colleagues (2016) provide an overview of assessment tools related to these constructs of positive well-being.

The wellbeing of care partners and caregivers strongly influences wellbeing and behavioral function of persons living with dementia. Therefore, caregiver wellbeing, self-efficacy, and perception of unmet needs should be a component of every assessment ( Jennings et al., 2016 ). Assessment tools have been developed to explore caregiver values and preferences, caregiver relationships, consequences and rewards of giving care, caregiver skills, abilities, and the motivation to provide needed care ( Whitlatch, Judge, Zarit, & Femia, 2006 ).

Challenges and Unmet Needs

Asking about current challenges and unmet needs (person living with dementia and care partner) facilitates empathy, enables tailored interventions, and informs the care planning process. Unmet needs commonly reported in the literature include: home maintenance, food, daytime activity, socialization, psychological distress, vision/hearing, self-care, and accidental self-harm. Persons living alone have more unmet needs than others ( Miranda-Castillo, Woods, & Orrell, 2010 ).

Designing person-centered approaches requires a detailed assessment of environmental and caregiving features that either support or detract from function, independence, and safety ( Gitlin, Marx, Stanley, & Hodgson, 2015 ). For community dwellers, an in-home assessment is recommended to identify safety concerns, environmental barriers to function and additional assessment data that may not be shared in more formal clinical settings (e.g., over-the-counter medications and supplements, pet-related concerns and living conditions). For persons living in residential care settings, the ability to observe the person’s usual activity within their residence offers a great deal of information about abilities, preferences, social interactions, stressors, and person–environment fit ( Brooker, 2005 ; Gaugler, Hobday, & Savik, 2013 ).

Reports of caregiver distress during any assessment occasion warrant referral to a team member with dementia-specific expertise in order to conduct a more in-depth assessment of needs, dyadic interaction, home environments, and opportunities to enhance function and safety. As the disease progresses and caregiving support needs are increased, the assessment of caregiver wellbeing and the balance of care provision between informal supporters and family caregivers versus formal/paid care providers become increasingly salient. The literature recommends assessment for neglect and abuse (physical, financial, emotional, or sexual), particularly in high-risk situations including aggressive behaviors and BPSD and caregiver variables including anxiety, depression, social isolation, low education, and emotional problems ( Wiglesworth et al., 2010 ).

The evidence supports the need to assess and address caregivers’ personal needs, including physical and psychological health, and the need to manage their own lives ( McCabe, You, & Tatangelo, 2016 ). Assessing caregiver needs and awareness of community and on-line resources is particularly important for minority populations who experience disparities in diagnosis and follow-up care ( Cooper, Tandy, Balamurali, & Livingston, 2010 ).

Cognitive Function and Decisional Capacity

Sudden or unexpected declines in cognition or function warrant referral to a health care provider to identify physical and mental health conditions that if undetected, may result in excess disability and cognitive dysfunction. Delirium (acute, potentially reversible cognitive impairment) is more common in persons with dementia ( Morandi et al., 2012 ) and a high index of suspicion is recommended for this life-threatening condition ( Inouye, Westendorp, Saczynski, Kimchi, & Cleinman, 2014 ). Serial assessment using reliable and valid cognitive assessment tools (by professionals with appropriate training and scope of practice) is recommended to identify potential acute changes in cognition or function. ( Wiener et al., 2016 ). Two recent systematic reviews of instruments to detect delirium may be useful to clinicians trained in their administration ( Morandi et al., 2012 ; Wong, Holroyd-Leduc, Simel, & Straus, 2010 ) and some researchers recommend that family members be educated to recognize delirium ( Paulson, Monroe, Mcdougall, & Fick, 2016 ).

Cognitive function should be assessed in a manner that optimizes success and preserves dignity ( Bryden, 2016 ). The assessor needs to understand not only the presence of cognitive and functional changes, but also the impact on the person living with dementia and care partners, and the implications for the goals, relationships, daily living, and engagement ( Brooker, 2008 ). It is important to recognize different cultural views of cognitive impairment and the acceptance of dementia as a diagnosis, and to use cognitive assessment tools that have been validated in populations for whom English is not the first language ( Wiener et al., 2016 ).

Cognitive assessment also supports person-centered care planning by guiding recommendations for activities and setting up appropriate expectations tailored to the person’s function ( Agostinelli, Demers, Garrigan, & Waszynski, 1994 ). For example, deficits in executive function may warrant task simplification, cueing, and activity-specific strategies. Deficits in language and communication may benefit from demonstration, hand-over-hand techniques, and specific strategies recommended by speech and occupational therapists ( Gitlin, Winter, Dennis, Hodgson, & Hauck, 2010 ). Tailoring activities to the person’s neurocognitive abilities and strengths may preserve dignity, prevent excessive stress-inducing demands, and prevent excess dependency, boredom, and learned helplessness.

Cognitive function includes the capacity to make decisions. Assessment of decisional capacity is most frequently discussed in the research literature in relation to medical treatment decisions. Decisional capacity (a clinical assessment) is distinct from competence (a legal determination) and is decision-specific. Involvement in everyday decision making is associated with quality of life and may include choices about living environments, types, and amount of support for daily activities and planning for a future of diminished capacity or function. ( Menne, Judge, & Whitlatch, 2009 ). Capacity assessment tools have been developed for treatment-related decisions Grisso, Appelbaum, & Hill-Fotouhi. (1997) and everyday decisions ( Lai et al., 2008 ). A specialized case of capacity assessment involves capacity for sexual decision making ( Wilkins, 2015 ). Illness may temporarily alter capacity and reassessment is indicated after appropriate treatment. Even in situations of diminished capacity, a person-centered approach supports that the values and wishes of the person living with dementia be sought, and included in the consideration of options ( Mezey, 2016 ).

Physical Function

Functional independence is a component of health-related quality of life ( Barbe et al., 2017 ) and is associated with care partner wellbeing and caregiving time ( Razani et al., 2014 ). Functional assessment includes both basic (bathing, dressing, grooming, mobility, toileting, feeding) and instrumental activities of daily living (managing finances, shopping, cooking, managing medications, housework, using transportation). Performance-based measures are recommended, in addition to obtaining data from multiple sources (e.g., person, care partner, direct observation, and measurement).

Functional assessment includes inquiry into any changes in day-to-day social, occupational, recreational, or physical function. Financial capacity and driving ability are sensitive but particularly important domains in the early phases of the disease, and it is recommended that these be discussed candidly with the person living with dementia and the care partner ( Frank & Forbes, 2017 ; Sudo & Laks, 2017 ).

Psychosocial Assessment

Whereas neurocognitive and functional assessments are often focused on detecting deficits or sources of illness and disability, assessment of psychosocial and emotional health focuses more on aspects of life that contribute to wellbeing. Qualitative studies emphasize two important themes related to quality of life: connectedness and agency ( O’Rourke, Duggleby, Fraser, & Jerke, 2015 ). Relationships with family, friends, long-term care staff, and other residents all contribute to the sense of connectedness in addition to harmonious relationships with place. Individualized meanings of home may be assessed and used as a basis for planning discrete experiences to improve quality of living ( Molony, 2010 ). Assessment of the person’s ability to experience autonomy and control, to set and meet achievable goals, and to maintain spiritual connections are essential to inform person-centered care planning ( Frank & Forbes, 2017 ).

Everyday Routines

Part of assessing day-to-day function and planning person-centered care includes reviewing daily habits, preferences, routines, and responses to various personal care activities. Evidence-based guidelines are available for assessment and care planning related to person-centered bathing, dressing, and oral care. ( Crandall, White, Schuldheis, & Talerico, 2007 ; Zimmerman, Sloane, Cohen, & Barrick, 2014 ).

Behavioral Symptoms

Behavioral symptoms have been conceptualized as a form of communication and expressions of unmet needs ( Algase et al., 1996 ) and/or a reflection of lower tolerance for stressors in the physical and psychosocial environment ( Hall & Buckwalter, 1987 ). A recent framework proposed by Kales and colleagues (2015) includes the quality of interaction between the caregiver and person living with dementia.

Behavior is universally acknowledged by researchers and families living with dementia as an essential component of assessment. Behavioral symptoms increase the burden of care for family and formal caregivers, often precipitate institutionalization and account for one-third of all dementia-related costs ( Herrmann et al., 2006 ; Toot, Swinson, Devine, Challis, & Orrell, 2017 ). Common behavioral symptoms include aggression, agitation, and apathy ( Kales et al., 2015 ). A whole-person assessment of behavior is the first step in understanding what these symptoms may signify so that the response is appropriate and person-centered. Careful assessment may identify triggering conditions or contexts that can be modified to reduce the likelihood of distress. In addition, assessing what aspect of the symptom is most distressing for the individual and caregiver will support individually tailored treatment strategies. This type of assessment is incorporated into successful models of care ( Gitlin, Winter, Dennis, Hodgson, & Hauck, 2010 ).

Once the behavior is well-characterized and untreated medical conditions are excluded as a possible cause, the second step is to assess for modifiable causes of the symptom. These precipitants then become targets for intervention. The investigation of these triggers involves astute observation of behavioral patterns. Behavioral logs can assist in identifying triggers that commonly include medications, pain, comorbidities, lost functional abilities, boredom, poor communication, task-focused care, and environmental characteristics such as noise, lighting, temperature, and crowding ( Gilmore-Bykovskyi, Roberts, Bowers, & Brown, 2015 ). The WeCare TM web-based application provides individually tailored guidance for caregivers and families assessing and managing behavioral symptoms ( Kales et al., 2017 ).

Kolanowski Boltz and Galick (2016) conducted a recent scoping review of causes or determinants of behavioral symptoms. A number of causes were common across several behavioral symptoms: neurodegeneration, type of dementia, severity of cognitive impairments, declining functional abilities, caregiver burden, poor communication, and boredom. These findings have implications for further assessment and care planning to support functional independence, improve communication, and prevent boredom.

Comorbidities

Co-occurring health conditions such as heart failure, diabetes or lung disease may amplify cognitive, functional, and behavioral challenges in persons living with dementia. Thorough investigation for co-occurring conditions may prevent disability and distress ( Wiener, 2016 ). These investigations include assessment of vision, hearing, oral health, communication, swallowing, nutrition, hydration, substance use, sleep, oxygenation, skin integrity, sexuality, continence, bowel function, and mobility and signs of infection or pain.

Older age, more chronic health conditions, polypharmacy, reduced mobility, advanced dementia, and/or communication impairments warrant a more comprehensive approach to physical assessment to identify undetected sources of illness or distress. There is a gap in the literature regarding the best methods to conduct a sensitive physical assessment in persons with dementia. The first author’s clinical experience suggests that a person-centered approach includes modification of the usual head to toe, palpation-before auscultation approach. Using less intrusive assessment techniques first (e.g., observation, resting auscultation), providing simple instructions and explanations, using a calm reassuring tone of voice and nonverbal communication strategies, are helpful in completing the assessment, particularly for persons in advanced phases of dementia. Referral to interdisciplinary colleagues for vision, hearing, and nutritional assessment is helpful when these team members are available. Vision loss may contribute to visual misinterpretation, nonrecognition and hallucinations. Vision screening has been shown to be feasible even in moderate to advanced dementia ( Chriqui, Kergoat, Champoux, Leclerc, & Kergoat, 2013 ). Inspection for wax impaction is part of routine geriatric assessment and is particularly important to prevent avoidable hearing loss in persons living with dementia.

Depression is common in early-stage Alzheimer’s disease. A recent meta-analysis found a pooled prevalence of major depression of 30.3% ( Goodarzi, Mele, Roberts, & Holroyd-Leduc, 2017 ) with a higher prevalence when criteria specifically developed for depression in dementia were used. While screening tools such as the PHQ-2 may be used mild stages of the disease, Goodarzi and colleagues (2017) found that the Cornell Scale for Depression in Dementia (CSDD) and Hamilton Depression Rating Scale (HDRS) had higher sensitivity and discriminatory ability than other instruments. Both of these scales include interview with persons with dementia and their caregivers. If a more in-depth assessment for depression is indicated, referral to a provider with mental health, geriatric, and/or dementia expertise is recommended.

Medications

Medications are a frequent contributor to cognitive dysfunction and a careful medication review is universally endorsed in the literature. Assessment includes identification of high alert medications and potentially inappropriate medications, as well as any medication usage or medication management challenges ( American Geriatrics Society [AGS], 2015 ; Johnell, 2015 ). While additional studies are needed to support predictive validity, the Mini-cog and Medi-cog screening assessments have demonstrated clinical utility in identifying the need for more assessment and support related to medication management and may be used by well-trained assessors ( Anderson et al., 2014 ).

Safety and Risk Reduction

One of the most valuable types of support for persons and care partners is planning for risk reduction. Persons living with dementia in early to middle phases are at increased risk for harm related to financial mismanagement ( Dong, Chen, & Simon, 2014 ), medication-related adverse events ( Wucherer et al., 2016 ), driving ( Rapoport, Cameron, Sanford, & Naglie, 2017 ), falls ( deRuiter et al., 2017 ), wandering, elopement, and getting lost ( Ali et al., 2016 ). Recommendations for community-based care include providing a referral to the Alzheimer’s Association and providing information about resources such as MediAlert® and the Safe Return® program, and the Alzheimer’s Navigator (an individually tailored assessment and management program available from the Alzheimer’s Association. Tools are available in the literature to support home safety assessment to identify opportunities to reduce the likelihood of avoidable injury ( Tomita, Sumandeep, Rajendran, Nochaiski, & Schweitzer, 2014 ).

Table 4 identifies safety issues cited in the literature that need to be periodically assessed to provide anticipatory guidance and reduce risk ( Amjad, Roth, Samus, Yasar, & Wolff, 2016 ). Persons living with dementia point out that skillful, empathetic communication strategies are needed to prevent these assessments from being conveyed as prophecies of a feared future, acknowledging that each person’s disease and trajectory are unique ( Taylor, 2007 ).

A person-centered approach requires that safety not be narrowly constructed to mean only physical safety. The person’s integrity may be threatened by risk-averse approaches that discount threats to personhood and dignity (ontological safety). Frank discussions about risk tolerance and risk mitigation are essential. The Alzheimer’s Association website has tools and resources to assist professionals in assessing and promoting safety while optimizing autonomy, including strategies to promote restraint-free care. Another excellent resource is the Rothschild Foundation guide for care planning processes ( Calkins & Brush, 2016 ) which was designed for nursing home settings and provides numerous clinical examples, quality improvement tools and templates to support care planning around risk-related activities while honoring individual preferences.

The range of safety-related topics illustrate the need for situational flexibility between wide-ranging, scoping assessment and in-depth, targeted assessment. In addition to driving safety, areas that are frequently in need of more detailed assessment include: nutrition ( Abdelhamid et al., 2016 ), pain ( Beer et al., 2010 ), oral care ( Delwel et al., 2017 ), falls ( de Ruiter, de Jonghe, Germans, Ruiter, & Jansen, 2017 ) and planning for restraint-free care ( Kopke et al., 2012 ). Restraint-free care is supported by all of the assessment practices recommended in this paper. Learning each person’s life history, values, habits, and preferences and conducting skillful assessment of contributors to wandering, behavioral symptoms, delirium, and falls, may reduce the need for restraints. System-wide policies for restraint-free care are recommended to guide this assessment and to raise awareness of preventable risk factors.

Advance Planning

While systematic reviews confirm that early attention to advance planning maximizes autonomy and increases the likelihood that the person living with dementia will have individual preferences and wishes honored, there is a gap in translating this knowledge into practice ( Robinson et al., 2010 ). The Institute for Healthcare Improvement and The Conversation Project have developed supportive materials for serious illness conversations tailored to the particulars of Alzheimer’s disease ( Bernacki & Block, 2014 ). Assessment of the individual and family’s knowledge and attitudes related to palliative care and symptom management (distinct from hospice care), inform the care planning process and may prompt referral to interdisciplinary team members for ongoing education and support (e.g., social worker, care manager, Alzheimer’s Association, and/or palliative care team).

Advanced dementia poses particular challenges for assessment. If the disease has affected the individual’s ability to communicate, care providers must have a high index of suspicion and vigilance in detecting delirium, illness, discomfort, hunger, constipation, impaction, urinary retention, infection, fear, grief, loneliness, and boredom. Skin breakdown, dehydration, swallowing difficulties, and aspiration are common threats to wellbeing that require timely detection and management. The more advanced the disease and/or the greater the number of comorbidities, the more frequent assessment should occur to identify potentially remediable causes of suffering ( Mitchell et al., 2009 ).

The Alzheimer’s Association End-of-Life Care Practice Guidelines (2007) contain detailed information and recommendations about decision making, planning, symptom management, and end-of-life care. Researchers have identified essential components of family-centered care at end of life and intensive individualized comfort care ( Lopez, Mazor, Mitchell, & Givens, 2013 ; Lopez & Amella, 2012 ).

A new Medicare Cognitive Assessment and Care Planning billing code (G0505) took effect in January of 2017 that provides reimbursement to practitioners for a clinical visit that results in a comprehensive care plan for persons with a documented cognitive impairment. The rules require a multidimensional assessment that includes cognition, function, safety, neuropsychiatric and behavioral symptoms, medication reconciliation, and assessment of caregiver needs. Transdisciplinary, collaborative care approaches are increasingly being recommended and evaluated ( Galvin, Valois, & Zweig, 2014 ). Collaborative assessment and care management may be particularly useful in reducing disparities in dementia care quality among caregivers with lower educational attainment ( Brown, Vassar, Connor, & Vickery, 2013 ). In any team-based approach, there needs to be agreement on who is accountable for coordinating and documenting assessment findings and follow-up actions.

Team care planning includes medical, nursing, direct care/personal care providers, care partners and other family, social workers, occupational therapists, physical therapists, speech therapists, registered dieticians, and pharmacists ( Wiener et al., 2016 ). This may require use of technologies to facilitate team collaboration, use of asynchronous written or electronic input and/or a care coordinator accountable for linking with all other team members, sharing and integrating all perspectives. If not already done, a list of strategies, approaches, therapies, and joy-enhancing activities should be gathered from family members, care providers, and all members of the team. This list must be frequently re-evaluated, revised, and used with sufficient flexibility to accommodate situational changes in the individual’s health, preferences and needs.

The person living with dementia should be involved in the care planning process and may need support in having their “voice” (including verbal and nonverbal communication) heard. The information obtained during whole-person assessment is used to plan care that meets the goals of the person living with dementia and their caregivers. Unfortunately, information contained in care plans does not always get shared with care providers in a systematic way. This is a barrier to person-centered care because many of the preferences and needs of residents are known to direct care workers as a result of their daily contact ( Abbott, Heid, & Van Haitsma, 2016 ). All staff must be included in the care planning process, particularly those who spend the most time with the person. This includes personal care assistants in community-based settings. Care plan implementation requires the use of tools to capture and distribute person-centered information to workers at the point of care ( Van Haitsma et al., 2014 ).

Others involved in the process include persons who care about, care with and/or care for the person with dementia. Using person-centered conceptual models to guide care and person-centered language in all documentation are two strategies that will increase the likelihood of person-centered planning. A number of outstanding resources are available to assist with care planning (see Table 3 ). The Dementia Action Alliance, a grassroots advocacy organization, provides white papers to support these practices (available at: http://daanow.org/ ).

Experiential, functional, behavioral, and health assessment provide the basis for ongoing care and referrals to other members of the interdisciplinary team. The outcome of comprehensive assessment is an interdisciplinary plan for function-focused care, rehabilitation, modification of tasks and environment, and activity-specific recommendations to improve engagement, enhance function, optimize choice, autonomy and comfort during personal care and decrease person/care partner stress ( Galik, Resnick, Hammersla, & Brightwater, 2014 ; Gitlin et al., 2015 ). Published guidelines recommend that care plans specifically address family wellbeing and the needs of caregivers and incorporate the person’s choices about the goals of care and end-of-life wishes.

Specific goals included in the plan include strategies to build on strengths, promote success, honor personhood, and support function (physical, cognitive, psychosocial, and spiritual). A quality assurance and performance improvement (QAPI) audit may be used to review whether plans of care respect the person’s unique preferences, consider the experience of the person and family, and focus on what really matters to the person and those who care deeply about them. The care planning process implies frequent reassessment about whether previous goals and preferences are being met and if not, what revisions need to be made ( Van Haitsma et al., 2015 ). Lack of goal achievement or behavioral challenges indicate a need for more comprehensive assessment and problem-solving leading to small individually-tailored trials with frequent checks to evaluate success. Consultation with advanced practice clinicians or dementia care experts may be sought if they have not previously been included in the process. It is particularly important to evaluate whether pharmacologic interventions are having the intended effect and providing benefits that outweigh the risks.

The time spent performing a comprehensive assessment and creating a holistic, person-centered plan will be wasted if that plan is not documented and shared in a manner that guides day-to-day care and experiences for the person and care partners. A study by Kolanowski, Van Haitsma, Penrod, Hill, & Yevchak (2015) found that certified nursing assistants in the nursing home setting did not have access to written information and/or the information that was available was out of date or too time-consuming to read.

Person-centered care interventions have demonstrated effectiveness in clinical trials ( Brooker et al., 2016 ; Kim & Park, 2017 ) but organizational barriers frequently prevent the implementation of these strategies. Future work is needed to create and sustain supportive environments that enable implementation of these practices.

As discussed throughout this manuscript, person-centered assessment and care planning focus on the unique needs and characteristics of the person. At present, many persons living with dementia do not receive person-centered assessment and care planning because of programmatic, organizational, and regulatory requirements and professional and provider practices that reflect the needs of staff and settings, more than the needs of the person with dementia. The following recommendations are intended to increase the use of assessment and care planning practices that focus on the needs of the person in a wide array of care settings, across types and stages of dementia, and conducted by professionals, paraprofessionals, and direct care workers, depending on their scope of practice and training.

Perform regular, comprehensive person-centered assessments and timely interim assessments.

Assessments, conducted at least every 6 months, should prioritize issues that help the person with dementia to live fully. These include assessments of the individual and care partner’s relationships and subjective experience and assessment of cognition, behavior, and function, using reliable and valid tools. Assessment is ongoing and dynamic, combining nomothetic (norm-based) and idiographic (individualized) approaches.

Use assessment as an opportunity for information gathering, relationship-building, education, and support.

Assessment provides an opportunity to promote mutual understanding of dementia and the specific situation of the individual and care partners, and to enhance the quality of the therapeutic partnership. Assessment should reduce fear and stigma and result in referrals to community resources for education, information and support. Assessment includes an intentional preassessment phase to prepare the assessor to enter the experience of the person living with dementia and their care partner(s).

Approach assessment and care planning with a collaborative, team approach.

Multidisciplinary assessment and care planning are needed to address the whole-person impact of dementia. The person living with dementia, care partners and caregivers are integral members of the care planning team. A coordinator should be identified to integrate, document and share relevant information and to avoid redundancy and conflicting advice from multiple providers.

Use documentation and communication systems to facilitate the delivery of person-centered information between all care providers.

Comprehensive, high-quality assessment is of benefit only if it is documented and shared with care providers for use in planning and evaluating care. Information must be current, accessible, and utilized.

Encourage advance planning to optimize physical, psychosocial and fiscal wellbeing and to increase awareness of all care options, including palliative care and hospice.

Early and ongoing discussion of what matters, including values, quality of life and goals for care, are essential for person-centered care. The person living with dementia’s preferences and wishes should be honored in all phases of the disease, even when proxy decision making is required. The individual and family should be referred to health care team members to provide ongoing education and support about symptom management and palliative care.

Further research is needed to inform the assessment process. Models of care are needed that balance the nomothetic and idiographic approaches to assessment in a person-centered, yet cost-effective manner. Future research is needed to investigate contributors to wellbeing and positive relationships in care partner dyads. Additional research is also needed to validate strategies for ensuring that best practices in person-centered assessment and planning are carried over to implementation at the point of care in both community-based and residential settings. The National Health Service Quality Outcome Framework in the United Kingdom explicitly lists “Ensuring that people have a positive experience of care” as a quality standard ( National Institute for Health and Care Excellence, 2013 ). This places the experience of the person living with dementia in the center of quality improvement efforts. A future challenge will be to integrate and measure outcomes of the relational processes needed to establish and sustain an “I-Thou” relationship, and support personhood, as envisioned by Kitwood.

This paper was published as part of a supplement sponsored and funded by the Alzheimer’s Association.

None reported.

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  • Published: 16 April 2019

Recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings: a cross national comparative mixed methods study

  • Michael Coffey   ORCID: orcid.org/0000-0002-0380-4704 1 ,
  • Ben Hannigan 2 ,
  • Sally Barlow 3 ,
  • Martin Cartwright 4 ,
  • Rachel Cohen 5 ,
  • Alison Faulkner 6 ,
  • Aled Jones 2 &
  • Alan Simpson 3 , 7  

BMC Psychiatry volume  19 , Article number:  115 ( 2019 ) Cite this article

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Involving mental health service users in planning and reviewing their care can help personalised care focused on recovery, with the aim of developing goals specific to the individual and designed to maximise achievements and social integration. We aimed to ascertain the views of service users, carers and staff in acute inpatient wards on factors that facilitated or acted as barriers to collaborative, recovery-focused care.

A cross-national comparative mixed-methods study involving 19 mental health wards in six service provider sites in England and Wales. This included a survey using established standardised measures of service users ( n  = 301) and staff ( n  = 290) and embedded case studies involving interviews with staff, service users and carers ( n  = 76). Quantitative and qualitative data were analysed within and across sites using descriptive and inferential statistics, and framework method.

For service users, when recovery-oriented focus was high, the quality of care was rated highly, as was the quality of therapeutic relationships. For staff, there was a moderate correlation between recovery orientation and quality of therapeutic relationships, with considerable variability. Staff members rated the quality of therapeutic relationships higher than service users did. Staff accounts of routine collaboration contrasted with a more mixed picture in service user accounts. Definitions and understandings of recovery varied, as did views of hospital care in promoting recovery. Managing risk was a central issue for staff, and service users were aware of measures taken to keep them safe, although their involvement in discussions was less apparent.

Conclusions

There is positive practice within acute inpatient wards, with evidence of commitment to safe, respectful, compassionate care. Recovery ideas were evident but there remained ambivalence on their relevance to inpatient care. Service users were aware of efforts taken to keep them safe, but despite measures described by staff, they did not feel routinely involved in care planning or risk management decisions. Research on increasing therapeutic contact time, shared decision making in risk assessment and using recovery focused tools could further promote personalised and recovery-focused care planning.

This paper arises from a larger study published by National Institute for Health Research (Simpson A, et al, Health Serv Deliv Res 5(26), 2017).

Peer Review reports

Improving the treatment and care of people with mental illness is amongst key priorities for health and social care in both England and Wales [ 1 ]. However, despite the shift to community-based models of care, considerable resources are still spent on acute inpatient beds: as much as £585million in 2009–10 [ 2 ].

In England in 2016–17, 101,589 people in contact with mental health and learning disability services spent time in hospital, with an estimated 45,864 people detained under the Mental Health Act (MHA) 1983 [ 3 ]. In Wales, 8723 admissions to hospital for mental illness took place in 2016–17, with 1776 of these taking place using sections of the MHA 1983 [ 4 ]. This volume of admissions requires considerable planning and coordination to ensure effective care is delivered consistently.

Health care is a devolved responsibility in the UK meaning that the context and delivery of mental health care is diverging between countries, providing a rich geographical comparison for research. In England the care programme approach (CPA), and in Wales care and treatment plans (CTPs), oblige providers to: comprehensively assess health/social care needs and risks; develop a written care plan; allocate a care co-ordinator; and regularly review care. CPA/CTP processes are now also expected to reflect a philosophy of recovery and to promote personalised care [ 5 , 6 ]. These similarities between CPA and CTP mask an important difference too however. CPA in England is central guidance while CTP in Wales is legislative and places legal obligations on health boards and local authorities. CTP in Wales uniquely has an associated code of practice, stipulating for example that only specifically qualified workers (e.g. registered mental health nurses, occupational therapists and clinical psychologists) can act as care co-ordinators [ 7 ].

The concept of recovery in mental health was initially developed by service users and refers to “a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness,” while developing new purpose or meaning [ 8 ]. (p527) The importance of addressing personal recovery, alongside more conventional ideas of clinical recovery [ 9 ] is now supported in guidance for all key professions [ 10 , 11 , 12 , 13 ]. To this has been added the idea of personalisation. This aims to see people and their families taking more control over their support and treatment options, alongside new levels of partnership and collaboration between service users (or citizens) and professionals [ 14 ]. (p3) Recovery and personalisation in combination mean tailoring support to fit the specific needs of the individual and enabling social integration through greater involvement of local communities [ 15 ].

The CPA/CTP are central to modern mental health care [ 16 ] yet there are few studies that explicitly explore the practices of care planning and coordination in community services and even fewer focusing on inpatient care planning [ 17 ]. A relatively rare example of the former is the recently completed COCAPP study [ 18 , 19 ]. In the UK national quality statements include the requirement that service users can jointly develop a care plan with mental health professionals, are given a copy with an agreed date to review it, and are routinely involved in shared decision-making [ 20 ]. National policies [ 1 , 6 ] outline expectations of recovery and involvement in decisions about treatment. This holds true for both informal and detained inpatients, with a requirement that reasonable adjustments are made where necessary to ensure that people are supported to live as full and socially participative lives as possible [ 21 ]. However, national quality reviews reveal limited evidence of service users’ views being listened to, with concerns being raised that control and containment are prioritised over treatment and support [ 21 ].

Earlier national reviews across both nations found that service users remained largely mystified by the care planning and review process itself, with significant proportions not understanding their care plans, not receiving written copies of their plan and often not feeling involved in the writing of care plans and setting of goals [ 22 , 23 ]. Clearly, there are significant problems with inpatient care planning with the Care Quality Commission (CQC) noting “significant gap between the realities observed in practice and the ambitions of the national mental health policy” [ 21 ]. (p5) The House of Commons Health Committee [ 24 ] subsequently reported widespread concerns about delays in care planning and an imbalance between a focus on risk rather than recovery.

Previously, the Healthcare Commission [ 25 ] measured performance on 554 wards across 69 NHS Trusts providing mental health acute inpatient services. They found that almost two-fifths of trusts (39%) scored weak on involving service users and carers; 50% of care plans sampled did not record the service user’s views; and nearly a third of care records (30%) did not record whether or not the service user had a carer. A third of all care records sampled (33%) showed that community care coordinators provided input into the service users’ care review meetings only “some or none of the time”.

The aim of this study was to identify factors that facilitate or hinder recovery-focused personalised care planning and coordination in acute inpatient mental health settings. As an exploratory study guided by the Medical Research Council (MRC) [ 26 ] Complex Interventions Framework we aimed to generate empirical data, new theoretical knowledge and greater understanding of the complex relationships between collaborative care planning, recovery and personalisation.

We conducted a cross-national comparative study of recovery-focused care planning and coordination in inpatient mental healthcare settings, employing a concurrent transformative mixed methods approach with embedded case studies [ 27 ]. A full account of our methods is provided elsewhere [ 28 ].

In summary, our study was informed by systems ideas emphasising connections between macro, meso and micro levels of organisation [ 29 ]. Cross-national comparative research involves “comparisons of political and economic systems …and social structures” [ 30 ] (p93) where “one or more units in two or more societies, cultures or countries are compared in respect of the same concepts and concerning the systematic analysis of phenomena, usually with the intention of explaining them and generalising from them” [ 31 ]. (p1–2) In this study, devolved government and the emergence of similar but distinct health policy, legislation and service development in England and Wales provided the macro-level national context.

A case study method [ 32 ] allows the exploration of a particular phenomenon within dynamic contexts where multiple influencing variables are difficult to isolate [ 33 ]. It allows consideration of historical and social contexts [ 34 ] and is especially useful in explaining real-life links that are potentially too complex for survey or experimental approaches [ 35 ]. The definitions of the case studies were predetermined [ 36 ], focusing on selected NHS Trust/Health Boards. Data collection at this meso-level included identifying local policy and service developments alongside empirical investigations of care planning and inpatient care, recovery, personalisation, therapeutic relationships and empowerment, employing mixed quantitative and qualitative methods. This design is represented in Fig.  1 .

figure 1

Diagram illustrating embedded case study design and integration of care planning and coordination in acute inpatient mental health settings

We selected six case study sites to match our earlier community study [ 18 ] so that comparisons and connections between community and inpatient services could be drawn [ 32 ]. These consisted of four NHS Trusts in England and two Local Health Boards in Wales that are commissioned to provide inpatient mental health services. In total 19 acute wards were selected for data collection. These sites reflected a mix of rural, urban and inner city settings in which routine inpatient care is provided to people with complex and enduring mental health problems. In each site, a single acute inpatient ward was chosen for further in-depth investigation and up to six service users, six multidisciplinary staff and four informal carers were sampled as embedded micro-level case studies [ 27 ]. Inclusion criteria for wards included that these were providing acute mental health care admissions facilities to the local adult population and had an established ward manager/team leader in post. Inclusion criteria for service user participants included that they were currently admitted to the in-patient facility, had been on the ward for a minimum of 7 days, 18 years or older, with a history of severe mental illness and able to provide informed consent. Staff inclusion criteria were staff working on inpatient wards involved in care planning or review. Full inclusion and exclusion criteria are provided elsewhere [ 28 ].

Sample size calculations

For the survey, an a priori sample size calculation was conducted using the G*Power software (version 3.1) [ 37 ]. The estimated sample size for service users was calculated for the global effect of a one-way multivariate analysis of variance (MANOVA) with six groups (sites), 17 outcomes (Recovery Self-Assessment Scale total (+ 5 sub-scales), Scale To Assess the Therapeutic Relationship total (+ 3 sub-scales), Empowerment Scale total (+ 5 sub-scales) and the Views of Inpatient Care Scale total), an α level of 0.05, power of 0.8 and a small effect size (f 2  = 0.029). This calculation suggested that a total of 276 service user participants was required.

We anticipated that with non-response and incomplete measures we would need to oversample, we therefore decided to recruit 300 service users ( n  = 50 per Trust/Health Board) and 300 inpatient staff ( n  = 50 per site). We anticipated that we would not achieve this sample size for informal carers and therefore aimed to recruit 150 informal carers ( n  = 25 per Trust/Health Board). This was because not every service user would have a carer, therefore analysis for the informal carers would be underpowered (estimated power was 0.44). The data for the informal carers was therefore anticipated to be exploratory.

Sample size calculations for qualitative interviews were based on previous research with similar populations by the co-investigators and others. Calculations were based on understanding of the practicalities and time commitments of recruiting and interviewing participants and analysing in-depth qualitative data; and the numbers required to feel confident that the findings would be transferable to other similar settings.

Instrumentation

The data collection measures reported in this paper are;

The Recovery Self-Assessment Scale (RSA) [ 38 ]: a 36-item scale measuring the extent of recovery-oriented practices. The scale addresses the domains of life goals, involvement, treatment options, choice and individually tailored services. Acceptable internal consistency of the RSA with Cronbach’s alpha has previously been demonstrated [ 18 ]. It was completed by service users, carers and ward staff. In the current study Cronbach’s alpha for the Total RSA scale for service users was 0.98 ( N  = 103) and for staff was 0.95 ( N  = 186); Life Goals subscale, for service users was 0.93 ( N  = 179) and for staff was 0.86 ( N  = 246); Involvement subscale, for service users 0.91 ( N  = 163) and for staff was 0.85 ( N  = 225); Diversity of Treatment options subscale, for service users was 0.81 ( N  = 172) and for staff was 0.77 (N = 225); Choice subscale, for service users was 0.81 ( N  = 217) and for staff was 0.68 ( N  = 254) and Individually Tailored Services subscale for service users was 0.85 ( N  = 159) and for staff was 0.71 ( N  = 253).

The patient and clinician versions of the Scale To Assess the Therapeutic Relationship (STAR-P and STAR-C) [ 39 ]: a 12-item scale assessing therapeutic relationships. A total STAR score is obtained by summing individual items. The subscales measure positive collaborations (possible scores 0–24), positive clinician input (possible score 0–12) and non-supportive clinician input in the patient version and emotional difficulties in the staff version (possible score 0–12). It was completed by service users and ward staff. Cronbach’s alpha for the total STAR-P scale for service users was 0.89 ( N  = 264) and for staff was 0.81 ( N  = 263); Positive Collaboration subscale, for service users was 0.92 ( N  = 279) and for staff was 0.81 ( N  = 269); Positive clinician input subscale, for service users was 0.72 ( N  = 282) and for staff was 0.56 ( N  = 268); and Non-Supportive clinician input subscale, for service users was 0.67 ( N  = 284) and for staff was 0.63 ( N  = 273).

The Empowerment Scale (ES) [ 40 ]: a 28-item questionnaire with five subscales: self-esteem, power, community activism, optimism and righteous anger. A total empowerment score is obtained by summing individual items and dividing them by the number of items. Subscale values can also be provided for ‘self-esteem-self-efficacy’, ‘power-powerlessness’, community activism and autonomy’, ‘optimism and control over the future’ and ‘righteous anger’. This scale was completed by service users. Cronbach’s alpha for the total Empowerment scale for service users was 0.82 ( N  = 255); Self-esteem-self-efficacy subscale, 0.91 ( N  = 272); Power-Powerlessness subscale 0.56 ( N  = 271); Community activism and autonomy subscale, 0.58 ( N  = 276); Optimism and control, 0.70 ( N  = 275) and Righteous anger, 0.40 ( N  = 281).

The Views of Inpatient Care Scale (VOICE) [ 41 ]: a 19-item patient-reported outcome measure of perceptions of acute mental health care that includes questions on involvement in care planning and ward round discussions. VOICE total score was obtained by summing individual item scores, possible total scores range from 19 to 114. The higher the total score for the VOICE the more negative the perception of the quality of care on the ward. It was completed by service users.

We further investigated internal consistency using alternative approaches, mean item-total correlations and Spearman-Brown prediction values (see Additional file  1 ). These additional analyses suggested that all subscales had acceptable internal consistency, although two subscales of the Empowerment Scale would merit further psychometric development.

We additionally conducted semi-structured interviews with ward staff, service users and carers. Interview schedules were based on our previous study and refined in consultation with our Scientific Steering Committee and Lived Experience Advisory Group (LEAG) and drawing on relevant literature. The aim of all interviews was to explore participants’ views and experiences of care planning and co-ordination, safety and risk, recovery and personalisation, and the context within which these operated. Care plan reviews and observations of ward rounds were also conducted but are not reported in this paper. In some cases participants on the case study sites completed surveys and research interviews but this was not a requirement of the study and the majority chose to participate in one part of the study only.

Research ethics

The study received NHS Research Ethics approval from the NRES Committee NRES Committee London – Fulham (Ref: 13/LO/2062) on 29th December 2014.

Considerable attention was given to ensuring the welfare of service user, carer and other participants and of the researchers. This included providing opportunities to pause or withdraw from interviews, assurances of anonymity and confidentiality and responding to concerns for people’s welfare.

Public and patient involvement (PPI) and study oversight

The study was developed and designed with full involvement of co-investigator and independent service user researcher (AF) and in consultation with SUGAR (Service User and Carer Group Advising on Research [ 42 ]). In addition, a Lived Experience Advisory Group (LEAG) met every 4/6 months during the study, consisting of seven service users and one carer with direct experience of inpatient mental health care.

The 12-member independently chaired Scientific Steering Committee (SSC) consisted of representatives with a clinical or research background from each of the participating NHS Trusts/Health Boards, as well as independent academics. One service user and one carer member also represented the LEAG.

Three Service User Researcher Assistants (SURAs)/Service User Project Assistants (SUPAs) were employed to recruit participants and conduct research interviews. All received training and ongoing support throughout the study.

Suitable local wards meeting inclusion criteria were identified with the assistance of local NHS Trust/Health Board principal investigators. Ward managers were approached by a researcher who explained the study, responded to any queries and invited them to participate. No service declined to take part. We sought approval to participate from two or three wards in each area and one of the three wards was then selected for in-depth case study of care planning including interviews. Each site was given a pseudonym to help maintain anonymity of participants. French names were chosen to avoid any accidental connection with English or Welsh sites or regions. The site names are:

All managers and ward staff involved in care planning or care plan review received written and verbal information about the study and were invited to participate in the survey (target n = 50 per Trust/Health Board).

Staff from participating wards were asked to identify service users who had been on that ward for a minimum of seven days, and who in their view potentially had the capacity to participate in the study. The service user was provided with written and verbal information by a researcher, who then ensured the person was able to provide informed consent to participate. Each participant was then given a survey pack to complete, with assistance if required. A thank you gift of £10 was given to service user participants on completion of the survey pack.

Ward staff were asked to give carer survey packs to carers (family members and friends) visiting service users on the ward (target n  = 25 per Trust/Health Board). The packs included an information sheet and a Freepost return envelope. Researchers working on the ward also approached carers to invite them to participate by completing measures.

Semi-structured interviews

Key personnel (registered nurses, ward managers, occupational therapists, psychologists and psychiatrists) were identified using purposive sampling to reflect meso and micro level functions. They were invited to participate in research interviews for the in-depth case study (target n  = 6 per case study ward; total n  = 36). Micro-level refers to the level at which face-to-face care is organised, provided and received. For our purposes meso-level refers to management functions that enable or structure micro-level work. Staff were given written materials describing the purpose of the study including the option to decline or withdraw at any time. Informed consent procedures were followed.

Service users approaching discharge were invited to participate in an interview about their experiences of care planning and jointly review their care plan (target n  = 6 per case study ward; total n  = 36). Informed consent procedures were followed. A thank you gift of £10 was given to service user participants on completion of the research interview.

Service users were asked to identify a carer (if applicable) to take part in an interview (target n  = 4 per case study ward; total n  = 24). Carers were contacted by telephone or when visiting, in the presence of the service user if possible. Informed consent procedures were followed.

Data management and analysis

Qualitative and quantitative data in each of the sites were considered on a within-group basis prior to a cross-case analysis aimed at identifying common themes and divergences. The between-group analysis of the quantitative data compared service users and staff across sites on key markers of the service user experience (recovery-oriented care, therapeutic relationship and empowerment). The quantitative analyses were conducted alongside the qualitative analyses in a convergent parallel design that facilitates the integration of mixed methods data [ 27 ]. Large scale survey data provides a broad picture while the interview data offers more micro detail. This is a pragmatic approach to mixed method research that can generate a more complete understanding of complex phenomena or processes. Quantitative and qualitative data analyses were conducted independently and subsequently synthesised to generate understanding of the links across micro, meso and macro levels than either approach could achieve alone.

Quantitative data

Data from the questionnaires were entered into SPSS version 21 [ 43 ] and distribution of the data assessed for normality using descriptive quantitative measures of skewness and kurtosis. There were few deviations from normality (2 of 27 scale outcomes exceeded the conservative criteria of +/− 1), one was small in the extent of deviation (within +/− 2) however one scale displayed larger deviation of skewness (Emotional differences subscale, Staff outcome on the STAR-C).

A missing value analysis was completed for the 27 scale outcomes. Moderate to high levels of missing data, not missing at random, were identified on a small number of items (mean level of missing data across the 27 scales/subscales was 20%, range from 6 to 55%). The service user version of the RSA questionnaire in particular had a moderate amount of missing data. Mean replacement was used to avoid unnecessary loss of cases from the analysis. The mean of the available items for the scale and participant were used for replacement of the missing values on the scale. A series of sensitivity analyses were conducted to determine what effect mean replacement would have in the primary analyses at different levels of replacement ranging from 20 to 50% replacement. Utilising a 50% mean replacement had no substantive changes in the key statistical parameters ( p -values and associated effect sizes) and the inferences drawn, therefore it was deemed appropriate to maximise the number of cases included in the analyses.

Descriptive statistics were calculated for the four measures (VOICE, RSA, STAR and ES). Where appropriate these scores were compared against reference values (VOICE, STAR and ES) or to the participant groups (RSA). Several unadjusted one-way Analysis of Variance (ANOVA) were conducted to compare differences between the six sites on the RSA, STAR, ES and VOICE measures. Subsequent Tukey post hoc tests were conducted to ascertain which measures differed between which locations. A series of one-way analysis of covariance (ANCOVA) were completed to adjust the analyses for potential confounders. The demographic variables that were chosen for service users were: age; gender; ethnicity and living status. Three care-related variables were chosen for service users: previous admissions; time in mental health services and time on the ward. The demographic variables that were chosen for staff were: age, gender, ethnicity, personal experience of mental illness and family experience of mental illness. Two clinical variables were also chosen: time working in mental health services and time working on the ward. The criteria for adjusted analysis between the ANOVA and ANCOVA were the p -value from the omnibus test, the adjusted means and the p-value from the post-hoc test. If the p-value from the omnibus test for the ANCOVAs were not substantively different from the ANOVAs then no further post –hoc analyses were completed. A series of independent t-tests were completed to determine if there were differences between service users and staff on the outcome measures.

Correlations of the service user data were completed to identify if there was a relationship between the scores on the outcome measures used. Six Pearson’s correlations were conducted to identify if there were relationships between the mean total scores for the measures RSA and VOICE; RSA and STAR-P; RSA and ES; STAR-P and ES; STAR-P and VOICE and VOICE and ES for all service user participants and by individual site. Cohen’s [ 44 ] effect sizes were used to describe the data (Small, r  = 0.10, medium r  = 0.30 and large r  = 0.50). A Pearson correlation was also completed for staff on the mean total scores for the RSA and STAR-C.

For all the ANOVA and ANCOVA analysis the statistical significance level was set at a level of 0.05. To account for multiple comparisons for the t-tests the significance threshold was raised to 0.005 to accommodate for the number of tests applied ( n  = 10).

Qualitative data

All digital interview recordings were professionally transcribed and checked against original recordings for accuracy and identifying information redacted, before being imported into QSR International’s NVivo10 qualitative data analysis software [ 45 ] for analysis using Framework method [ 46 , 47 ]. The Framework matrix used was developed a priori from the interview schedules, with sections focusing on organisational background and developments, care planning, recovery, personalisation, safety and risk, and recommendations for improvement. Each matrix section also had an ‘other’ column for the inclusion of data-led emergent categories. Once all charting was completed, second-level summarising was undertaken to further précis data and to identify commonalities and differences.

Data collection across the six sites is summarised in Table  1 and consisted of n  = 301 service users (target was 300), n  = 290 members of staff (target was 300), n  = 28 carers (target 150) completing survey measures.

We completed 31 research interviews with staff (target was 36), 36 with service users (target was 36); and nine with carers (target was 24).

Cross-site analyses will be presented for the four service user questionnaires (VOICE, RSA, STAR-P and ES) followed by a cross-site analysis of the two staff questionnaires (RSA and STAR-C).

Service users

To explore cross-site differences one-way ANOVAs of all total score and subscales were conducted and revealed that there were no global differences across the sites for any of the four measures. Table  2 shows the mean item scores, alongside the parameters of significance for service user participants.

For staff, one-way ANOVAs were conducted for the mean RSA and STAR-C total scores and the subscales (Table  3 ). There was a significant difference between the research sites in the mean RSA total score (F 5, 279) = 6.35, p  <  0.001, η 2  = 0.32) and the mean total score for the STAR-C (F 5, 273) = 3.02, p  = 0.011, η 2  = 0.23). There were also significant differences found in all of the mean item subscale scores of the RSA and the positive collaboration subscale for the STAR-C. Table 3 shows summary scores for staff.

When using Artois and Champagne as reference sites (the sites with the lowest scores) Provence and Dauphine sites scored significantly higher for the mean RSA total score indicating more recovery focused care (see Fig.  2 ). This scale measures some important perceptions that may have a significant effect on patient outcomes and concordance to care and collaboration with service users. Subsequent Tukey post-hoc tests revealed that staff in Artois (3.36, s.d. = 0.59) score significantly lower than Provence (3.76, s.d. = 0.56, p  = 0.009, CI.95–0.73, − 0.07, Cohen’s d = 0.69) and Dauphine (3.74, s.d. = 0.53, p  = 0.009, CI.95–0.70, − 0.06, Cohen’s d = 0.68). Staff in Champagne (3.21, s.d. = 0.46) score significantly lower than Provence ( p  <  0.001, CI.95–0.92, − 0.19, Cohen’s d = 1.07) and Dauphine ( p  <  0.001, CI.95–0.88, − 0.19, Cohen’s d = 1.07).

figure 2

Mean Total RSA score for staff +_95% CI

STAR-C questionnaire

There were no significant differences in the staff responses across sites for the Positive Clinician Input subscale (F (5,272) = 1.53, p  = 0.182, η 2  = 0.16) and the Emotional Difficulties subscale (F (5,270) = 1.91, p  = 0.092, η 2  = 0.16) There were however significant differences found between sites for the Positive Collaboration subscale (F (5, 274) = 2.42, p  = 0.036, η 2  = 0.20) and the STAR-C Total score (F (5, 273) = 3.02, p  = 0.011, η 2  = 0.23).

STAR-C positive collaboration

Burgundy performs significantly better for the mean Positive collaboration subscale score than Artois (see Fig.  3 ). This scale measures some important perceptions around rapport and shared understanding of goals focused on mutual openness and trust. Subsequent Tukey post-hoc tests revealed that staff in Artois (17.17, s.d. = 2.65) score significantly lower on the subscale than Burgundy (18.86, s.d. = 2.57, p  = 0.019, CI.95–3.20, − 0.18, Cohen’s d = 0.65). There were no significant differences between all of the other sites on this subscale.

figure 3

Mean Positive Collaboration subscale score for staff ±95% CI

STAR-C Total

Burgundy performs significantly better for the mean positive collaboration subscale score than Artois (see Fig.  4 ). This scale measures some important perceptions that may have a significant effect on patient outcomes and concordance to care and collaboration with service users. Subsequent Tukey post-hoc tests revealed that staff in Artois (36.08, s.d. = 4.18) score significantly lower on the subscale than Burgundy (39.33, s.d. = 4.31, p  = 0.011, CI.95–5.76, − 0.75, Cohen’s d = 0.77). There were no significant differences between all of the other sites on total score.

figure 4

Mean STAR-C Total score for staff ±95% CI

Correlations between outcome measures

Pearson’s correlations were used for the service user survey scores to determine if there were associations between responses on the four scales. Table  4 shows that there is a strong negative correlation between the RSA and VOICE ( r  = −.70, n  = 285, p  <  0.001). This shows that there is an inverse association between the recovery-oriented focus and the negative perception of quality of care amongst service users meaning when recovery-oriented focus was high the quality of care was viewed highly. There is also a positive correlation between the RSA and the STAR-P ( r  = .61, n  = 282, p  < 0.001), indicating an association between the recovery-oriented focus and ratings of the quality of therapeutic relationships amongst service users. There is also a strong negative correlation between the STAR-P and VOICE scale ( r  = −.64, n  = 294, p  <  0.001). There is also an inverse association between the quality of therapeutic relationships and the negative perception of quality of care meaning that when therapeutic relationships are scored highly the perception of quality of care is also scored highly. There are negligible relationships between the RSA and ES; STAR-P and ES and the VOICE and ES.

A Pearson’s correlation was completed at the global level with all participants to determine if there were associations for staff scores between the responses on the two questionnaire scales. This correlation were completed using pairwise deletion. There is a small to moderate correlation between the RSA and STAR-C ( r  = −.28, n  = 279 p  < 0.001).

When comparing the correlation between the RSA and STAR-C (see Table  5 ) there is a considerable amount of variability across sites. There is a large correlation in Burgundy ( r  = 0.50, n  = 43, p  = 0.001). There are moderate or small to moderate correlations in Artois ( r  = 0.28, n  = 56, p  = 0.034), Languedoc ( r  = 0.35, n  = 47, p  = 0.015) and Provence ( r  = 0.28, n  = 56, p  = 0.034). Only small correlations were found in Champagne ( r  = 0.16, n  = 41, p  = 0.331) and Dauphine ( r  = 0.35, n  = 50, p  = 0.015).

Across all of the six research sites staff score significantly higher than service users on the scale to assess therapeutic relationships. In Burgundy and Dauphine the same pattern is present across all of the subscales. Positive clinician input was scored higher by staff than service users across the six sites (see Table 2 ).

Qualitative findings

Table 1 summarises the characteristics of each of the six meso-level case study sites and the types and quantity of data generated in each. Illustrative quotations used below are labelled with the initial of the site pseudonym; then ST, SU, or CA for staff, service user or carer; and their unique number, e.g. B-ST-001 (Burgundy-Staff-001).

Care planning and coordination

Staff across sites talked of the importance of collaborative care planning. Many also spoke of the value of plans being kept up-to-date with service users actively involved, and of plans being used as a way of collecting multidisciplinary contributions and of helping manage transitions between hospital and community. For example,

“[B]ringing a person’s care all together really, so it’s like a standard to work around, that it’s all centred around the patient’s care, so everything works for them in the best way, I think.” (L-ST-103)

However, staff, service user and carer interviews all revealed gaps between shared aspirations and realities, even where service users drew attention to receiving good quality care. Staff accounts of routine collaboration with service users in care planning contrasted with service user accounts which pointed to lack of involvement. In all sites some service users report that they were not involved in the planning of their care, were unaware of the content of their care plans or had not received copies, or did not feel a sense of care plan ownership. For example,

“There isn’t a treatment plan. There’s no treatment, there’s just containment. Walking to the shop to get a newspaper isn’t treatment. There’s no therapy here.” (C-SU-103)

Staff sometimes spoke of service users’ unwillingness or inability to collaborate in care planning, or of the barriers to collaborating brought about by the introduction of electronic records. Lack of a shared language was cited as a barrier in one inner city site (Dauphine). Staff in Burgundy said how the all-Wales CTP template was not well-suited to the short-term nature of acute hospital care with some domains (e.g., housing) emerging as higher priority than others.

“I think I struggle with the principles [of CTP] and how that fits perhaps into the ward – the confusion that still exists is very much present in terms of the fundamentals of it.” (B-ST-102)

Coherence and continuity in care across hospital and community interfaces were identified as important by many of those taking part, and examples of detailed and collaborative discharge planning involving staff and service users were given. Innovations were also described, such as ‘interim discharge summaries’. However, rapidly arranged discharges caused some concern with little time then available for considered planning, one service user recalled being ‘pulled in out of the blue’ to be told ‘right, you can go’ (P-SU-102).

Two types of care plan review were described: formal, typically weekly, multidisciplinary meetings chaired invariably by consultant psychiatrists and daily handovers where care on a more immediate basis was reviewed by staff. Formal ward rounds were described as key events by staff and as places where progress and plans could be reviewed in a multidisciplinary context. Service user views and experiences of these differed, within and across sites. For some they were helpful, serving as opportunities for catching up with psychiatrists and the whole multidisciplinary team.

“Sometimes you’ve got a load of people in there and you sort of feel a bit like you’re on stage, you know like the spotlight’s on you, sort of thing. But yeah. I’ve had problems with ward rounds but more recently things have been OK, I’ve been able to sort of express myself more.” (P-SU-104)

Some service users also described the opportunity to plan and prepare for formal ward round participation. Others spoke of limited time to fully consider their needs, of excessive jargon being used and of inflexibility over ward round scheduling.

Safety and risk

Assessing and managing risk were customarily seen by staff as central parts of the work of planning and providing care so that risk assessments were described as proliferating so much they were “ coming out of your eyeballs” (P-ST-101). Formal ward round-based review meetings were named as a place for risks to be discussed although not necessarily in the presence of service users. Some staff also talked of the particular issues surrounding risk and decision-making in the care of service users who were detained. Risks mentioned by staff included those to self and others, with some also noting the dangers of over-estimating risks and the importance of attending to strengths and of positive risk-taking.

“ if you let the risk rule over the actual care plan then you’re never going to get anywhere .” (L-ST-102)

Most service users talked of their safety being considered and attended to, sometimes giving specific examples of this in action (e.g., through removal of objects and the use of observations), even though risk assessments and management plans were often not actively discussed with them. Others did, however, talk of feeling unsafe in hospital and of asking for more staff.

Definitions and understandings of recovery varied amongst staff, service users and carers, as did views of the role of hospitals in promoting this. Participants, in many cases, were also aware of the disparate meanings of ‘recovery’. Some staff (e.g., in Artois) viewed recovery as problematic in the inpatient context, saying that this raised expectations or was too poorly understood to help effective care planning.

“ I think it’s about being realistic as well. … certainly it’s about fostering hope, looking for things as well, and working towards those things, but in an acute ward where people can’t … leave [the ward] ” (A-ST-106)

In Languedoc, antipathy to the idea of recovery was reported by some staff who challenged both its meaning and utility. Most service users said that hospital had helped (e.g., to stabilise medication), though some complained of having been largely left to their own devices or subjected to containment. The use of tools to aid recovery (e.g., Recovery Star) were occasionally mentioned (e.g., in Burgundy), but in most cases these were either not deployed or were described as being more suitable beyond the acute hospital care context. Service users and carers revealed a range of views around recovery, from the cure of symptoms, to the prospects of life without medication, to the idea of coming to terms with difficulties.

“getting rid of the voices and what I see. That’s my recovery” (P-SU-101).
  • Personalisation

The term ‘personalisation’ was not a familiar one, with few revealing knowledge of personal budgets, “ It doesn’t mean anything, it just sounds like a made-up word .” (L-SU-102).

In all settings there was recognition of the idea that care and services should be oriented to the individual. Whilst some staff talked of inpatient care as being person-centred there was also widespread recognition of the challenges to this (e.g., tensions between different approaches to providing care, the fact that staff only get to know people as patients, and the relative (un)availability of resources). Within and across sites there were differences in service user views and experiences of individually tailored care. Some were clear that hospital had been pivotal in their care, “ without this place it would be the end of me ” (C-SU-105). Others were equally clear that their care had not been personalised, or talked of their care at home being more personalised. Carers gave positive accounts of care provided although most remained uncertain about the term personalisation,

“ I guess personalisation means the way her treatment was personalised for her and I guess it was, because everyone is different and everyone needs different help, but I don’t really know what you mean.” (P-CA-101)

The aim of this study was to identify factors that facilitate or hinder recovery-focused personalised care planning and coordination in acute inpatient mental health settings. The intention was to generate new theoretical knowledge and greater understanding of the complex relationships between collaborative care planning, recovery and personalisation.

Comparison and consideration of our survey results and interview data across sites provides some reason for optimism concerning the overall quality of mental health inpatient care but also indicators of areas where greater attention may be required.

We found no global differences across the six sites on the service user measures. The VOICE measure [ 41 ] examined service users’ perceptions of inpatient care and found marginally lower scores than the reference value [42]. However, the mean scores in all six research sites in this study were lower (so more positive) than those reported in a recently published study which examined different inpatient service models over a period from 2008 to 2010 [ 48 ]. We found that service users leaned towards a positive perception of the wards but there was wide variation within sites, suggesting a mix of views. These results converge with our research interview data showing service users being largely positive about their care, acknowledging being treated with dignity, respect and compassion. This was irrespective of legal status. Those carers interviewed also spoke positively about care provided and attitudes of staff.

Staff spoke of the challenges of collaborating on care planning with service users in severe mental distress or lacking insight and this is likely to include those formally detained. However, despite specific questions related to the legal status of services users, this was not explicitly identified as an issue perhaps reflecting the now high proportion of inpatients legally detained.

On ratings of the quality of therapeutic relationships, across all six sites staff consistently rated these relationships significantly more positively than did service users. The STAR-P measure used was initially designed for rating the one-to-one relationships that service users have with care coordinators in community teams [ 15 ] so it may be that, despite having a ‘named nurse’, the more dispersed nature of relationships with a number of ward staff over days and weeks, across shifts and 24-h care weaken any rating. Inpatient care also includes the greater likelihood of restrictions, limitations, rules and regulations necessary to provide a safe environment [ 49 ]. First- or second-hand experience of coercion and containment are also likely to be more prevalent in an inpatient setting [ 50 ]. Nevertheless, the need for further investigation to identify how positive relationships can be mutually achieved is indicated.

There was a strong perception across sites that staff were aware of policy drives to provide a greater focus on recovery, to provide respectful, compassionate and dignified care. Most staff articulated clear values and understandings reflecting core components of the focus on recovery as well as other initiatives that have been promoted in an attempt to improve inpatient services, such as the Royal College of Psychiatrists’ Accreditation for Inpatient Mental Health Services (AIMS) [ 51 ], Bright charity’s Star Wards [ 52 ] and most recently, the mental health nurse-led evidence-based intervention, SafeWards [ 53 ].

Staff participants suggested that severity of illness and/or lack of insight sometimes means that collaborative care planning is difficult to achieve, that there was often insufficient time to devote to this task, or that some service users were unwilling or unable to collaborate on care planning. Staff found it difficult to discuss care with service users especially where there was a mismatch in goals and expectations and limited advice on what a good care plan looks like or on how to identify achievable goals. Some of these barriers such as staff views on severity of illness have been found in other studies and highlighted in systematic reviews of barriers to involvement [ 54 ] and the consistency of this finding across our study sites can be read in a number of ways. First, it is undoubtedly the case that some people admitted to inpatient services are in severe distress and the process of discussing and negotiating a care plan in those first few days is unlikely to be a priority for them.

A second reading is that mental health professionals despite their claimed interest and support of involvement actually struggle to put this idea into practice and may need some guidance to achieve the aspiration of true collaboration. A possible contributor here was highlighted by both service users and staff and this relates to inflexible documentation and information technology on inpatient wards. In tandem these two elements prevent service users and staff writing care plans together as staff have to leave to type up a care plan once discussed, service users feel removed from the process and unable to alter the document which can often be presented to them without adequate explanation.

Services are also pressured to meet organisational demands and staff may simply not prioritise collaboration with service users. Service users report that time with staff is highly valued but for the most part was a limited resource. Time is an important and taken for granted feature of social life; it is used by individuals to impose order, understand and handle discontinuities [ 55 , 56 ]. A universal expectation reported by staff and service users in this current study was that individual one to one time would provide the means for problem resolution, help establish rapport and trust and ultimately engender a sense of collaboration towards preferred goals. However, time was a scarce resource and organisational schedules were reported to quickly over-ride those of the service user and their primary nurse.

Interprofessional ward rounds were of critical importance to service users and staff alike as the site for discussion, planning and review. Service users and staff may experience the timetabling of ward rounds differently, for example there may be diverse perceptions of scheduling delays or contradictory understandings of what happened [ 57 ]. For service users in our study ward rounds involved anxious hours waiting to be called, followed by sometimes short but overwhelming or intimidating experiences in the meeting itself [ 58 ]. It was noted that few service users were adequately prepared on what to expect. Some told us they had expected to meet only the doctor but found themselves shown into a room full of unfamiliar faces, others felt that their contributions were not valued or that they had been poorly treated. For people who are already distressed and anxious about their treatment or future outcomes it seems ward rounds handled poorly can worsen their sense of efficacy and discourage attempts to achieve involvement.

Both staff and service users said that reviewing care plans in ward rounds would help mark progress towards agreed goals. This finding from our research interviews aligns with our quantitative survey showing that participants rated highly the recovery language used by staff and the regular monitoring of progress towards recovery goals. Additionally, the information needs of service users could be better met by helping them prepare for ward rounds, including determining expectations and the agenda. In addition it was suggested to us that service users be given summaries of ward round outcomes.

Recovery, therapeutic relationships and care planning

The focus of recovery for many service users was around medication and symptom suppression (perhaps reflecting the primary focus of inpatient care) indicating a more ‘clinical’ as opposed to a ‘personal’ concept of recovery [ 9 ]. In some sites, there was greater ambivalence around the suitability or relevance of ‘recovery’ in inpatient care, particularly where people are very unwell. There may be tensions with working in recovery-focused ways when people are formally detained. It is possible however that this is the very time where a recovery-focused approach would be most powerful.

Our data on recovery shows convergence between results from standardised measures and findings from qualitative research interviews. Across five of the six sites service user participants rated highly the use of recovery language from workers and services alongside their perspective that workers believe that people can recover and participate in their own life choices. Service users also rated highly that there is regular monitoring of progress towards their recovery goals. Workers rated these items highly too suggesting that notions of recovery and therapeutic optimism were supported. Qualitative data indicate staff recognised the complex and individual nature of recovery. For example some staff saw a more recent orientation towards recovery focused care as representing the shift from previous authoritarian and prescriptive asylum based care to more collaborative models that encourage patient and family involvement.

There was a strong association amongst service users between their perceptions of recovery-oriented care and their perception of the quality of care on the ward. Likewise there were close correlations between the therapeutic relationships and the perception of quality of care. These findings were robust and consistent across all research sites. Whilst it is not possible to determine which factor might be influencing which, it does suggest an important interrelationship between service users’ subjective valuing of their relationships with staff, the quality of inpatient care and the recovery-focus of the service.

Across all sites staff consistently scored practices as more recovery-oriented than did service users. Our interviews, however, revealed ambivalence and a range of staff perspectives on recovery in line with previous research [ 59 ]. The concern that recovery creates ‘unrealistic’ expectations can perhaps be read as anxiety about what services have to offer to achieve this desired outcome. It may be that participants are simply acknowledging that recovery opportunities are hindered in settings where insufficient space is afforded to wider structural and social issues that give rise to and maintain mental distress. All participants appear to recognise the non-linear complex nature of recovery but place the emphasis differently.

One site that scored recovery highly, Dauphine, had made local attempts to introduce innovations such as service user-focused ‘This is Me’ care plans and short summary ‘management plans’, but these are in addition to standard documents and care plans, adding to workload. Interestingly, in Wales service user participants recognized that their goals were being monitored on a regular basis. This was appreciated to a lesser extent in England with just one site scoring this highly which may be a positive indication of the use of the structured care and treatment plan (CTP) approach in Wales.

Risk and safety remain key concerns for mental health workers [ 60 ] and issues around safety and risk are reported to be central to inpatient work for staff. In the mental health system more widely risk is constructed as an unwanted outcome arising from the actions or behaviours of individuals with mental health problems. In this sense risk is seen to emanate from the person who is seen as the chief agent of unwanted harmful behaviours. Harm does occur of course and mental health services appear to be chiefly concerned with harms from the person to themselves or others. For example, there are approximately 5500 suicides each year in the UK, 30% of which are known to mental health services [ 61 , 62 , 63 ]. Risk of suicide in the transition from inpatient care is now firmly established [ 64 ] and there is some suggestion that this risk has been transferred from inpatient to crisis resolution and home treatment services [ 65 , 66 ]. Harm to others is a much rarer event but nevertheless is likely to have significant negative consequences for the victim, the individual with mental health problems and their family, and the wider system including individual workers such that risk averse practice is common [ 67 ]. The pressure to ensure safety and avoid blame appears to be omnipresent in mental health services.

Coherence and continuity in care across hospital and community interfaces is known to be important in delivering safe, supportive mental health care [ 68 ] and were identified as important by many of those taking part in this study, with examples of detailed and collaborative discharge planning involving staff and service users given. Innovations were also described, such as ‘interim discharge summaries’. However, participants also reported rapidly arranged discharges with little time for discussion or planning. Decisions on movement through phases of inpatient treatment will in part depend on the presenting symptomatology of the person, an assessment of their risk status, their needs for treatment and an assessment of their post discharge needs such as accommodation [ 69 ].

Staff acknowledged tensions around sensitive discussions and especially with people detained. Workers openly acknowledged that this was to avoid difficult conversations but others seemed less aware that in denying service users access to knowledge about their risk that they are effectively excluding people from participation in decisions about their care [ 70 ]. Previously we have noted that workers position risk assessment as legitimate work despite limitations in the predictive power of these judgements as one way of gaining normative certainty [ 71 ].

Here, unlike in the community study [ 18 , 71 ], service users seemed to be more aware of their safety being considered and managed in that they understood why certain items were removed or restrictions were imposed. Some service users spoke of not feeling safe on wards as reported in previous studies [ 72 , 73 ] and this needs to be considered in ongoing discussions and policy developments on safe staffing [ 74 ]. It remained a curious finding that while workers saw risk assessment as central to their efforts that they appear to largely exclude the service user from meaningful discussions about these.

Drawing on the evidence presented here, personalisation is not widely recognized as a concept and not actively used in inpatient services by staff or service users, although there was wide discussion amongst staff of aiming to provide personal care or a personalised approach to care.

Staff spoke about some of the constraints and challenges in trying to work in a personalised way and these included a lack of resources, short ward stays, service users being formally detained, disagreements, risk behaviours, limited capacity, and a primary focus on medical treatment. It was recognised that to enable personalised care, it was necessary to have the time to get to know people as individuals and to provide some element of continuous care. Too often this was difficult to achieve in inpatient settings. Staff in the Welsh sites thought that the format of the CTP process and care plan was supportive of working in a personalised way and helped service users and staff get to know each other better.

Some service users were clear that their care was very personalized and that staff had considered their unique needs with several good examples provided. Others felt that inpatient care was more routine and standard for all and that individually tailored care was less possible in hospital, especially when people are detained. However, it was notable that some wards and staff were able to provide care in a more personalised way and support should continue to be given to achieve this everywhere. Personalisation is an integral component of a recovery-focused approach to mental health care and needs to be promoted and supported as such [ 75 ].

Strengths and limitations

Achieving our target numbers for each grouping on the survey was challenging. Service user numbers were achieved but fell just short for staff. To achieve our target recruitment figures we approached all eligible participants meaning that our sample was not randomly selected. Despite considerable efforts we were unable to recruit sufficient numbers of carers. Researchers in the field reported how few carers visit wards, often preferring to meet service users elsewhere. The difficulties of involving carers in studies of inpatient mental health services has been reported elsewhere [ 76 ] and poses a particular challenge for researchers keen to include the views of family members and friends.

Due to the nature of the survey it is not possible to make comparisons between responders and non-responders as we had no access to data for non-participants. There was a moderate level of missing data for the RSA scale completed by service users, possibly due to some of the difficult language used and the community focus of the measure. As a consequence, more detailed analysis of covariations within the data was restricted by lack of power.

The interview data is rich and the framework method provided a time-consuming but structured and visible method of organising, analysing and comparing that data within and across sites. We believe the framework method and detailed presentation of results supports the transferability of these findings to other similar services. The involvement of service users and carers throughout the study as researchers and advisors has also provided added value to the study through additional viewpoints and interpretations.

The findings of this cross-national, multi-site mixed methods study suggests positive practice is taking place within acute inpatient wards with evidence of a widespread commitment amongst staff to provide safe, respectful, compassionate care with strong values underpinning practice. Whilst ideas of recovery were evident amongst staff there was some uncertainty and discrepancy about the relevance of recovery ideals to inpatient care or the ability of people experiencing high levels of distress to engage in recovery-focused approaches. However, service users saw inpatient admissions as a necessary stage in stabilising their mental state, with medication an important component, and often appreciated the efforts that were made to keep them safe and to help them take the next tentative steps on their recovery. They also rate highly staff using recovery-focused language and values. Many spoke of care being personalised with examples given of staff being very responsive and considerate to particular needs or concerns. Carers often similarly described positive views of patient care. However, whilst service users valued the relationships they have with staff on the wards, they do not rate these as highly as staff. As discussed earlier, this is perhaps not surprising given all the tensions and anxieties associated with an inpatient stay, but this perhaps can best be summarised as ‘doing well, but could do better’.

Staff were clearly able to articulate the care planning processes and documentation required of them and described some of their frustrations with lengthy, unwieldy forms and at times distancing computerised systems that required more time in front of monitors than in conversation with service users. Most staff also spoke of their understanding and efforts to involve service users, and carers and families where possible, in the care planning process. However, most service users did not really appreciate the written care plan as an integral or important part of their experience and many did not have copies or could not find them. The majority of service users did not feel they had been genuinely involved in the process. Unfortunately, in relation to service users receiving sufficient time with nursing staff and being involved in planning their care, very little progress appears to have made since the report of the Healthcare Commission of nearly a decade ago [ 25 ].

Issues of risk and safety are ever-present in mental health services and it was clear that this was central to the work of staff, whilst they displayed an awareness of the sensitivities and challenges involved. Service users, and carers, were often aware of efforts being made by staff to keep them safe. However, involvement of service users in discussions about personal risk factors and safety is challenging and requires greater training and support to encourage staff to develop the skills and confidence to undertake such sensitive and important work with confidence.

Abbreviations

Analysis of Covariance

Analysis of Variance

Care Programme Approach

Care Quality Commission

Care and Treatment Planning

Empowerment Scale

Lived Experience Advisory Group

Multivariate Analysis

Multidisciplinary Team

Medical Research Council

National Health Service

National Research Ethics Service

Recovery Self-Assessment

Scientific Steering Committee

Scale to Assess the Therapeutic Relationship – Clinician version

Scale to Assess the Therapeutic Relationship – Patient version

Service User and Carer Group Advising on Research

Service User Project Assistants

Service User Researcher Assistants

United Kingdom

Views of Inpatient Care Scale

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Acknowledgements

All members of the Lived Experience Advisory Group, the Study Steering Group, the service user researchers and research staff who ensured the success of the study.

The project reported in this article was commissioned and funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme (HS&DR 13/10/75). The NIHR had no role in the design of the study and collection, analysis, and interpretation of data or in writing of the manuscript. The views and opinions expressed here are those of the authors and do not necessarily reflect those of the HS&DR programme, NIHR, the National Health Service (NHS) or the Department of Health and Social Care.

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Michael Coffey

School of Healthcare Sciences, Cardiff University, Cardiff, CF24 0AB, UK

Ben Hannigan & Aled Jones

Centre for Mental Health Research, School of Health Sciences, City, University of London, Northampton, Square, EC1V 0HB, UK

Sally Barlow & Alan Simpson

Centre for Health Services Research, School of Health Sciences, City, University of London, Square, EC1V 0HB, Northampton, UK

Martin Cartwright

Centre for Academic Mental Health, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK

Rachel Cohen

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Alison Faulkner

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Contributions

MCo contributed to the design of the study, data collection, analysis, interpretation, write-up and final edit of the paper. BH contributed to the design of the study, data collection, analysis, interpretation, and write-up of the paper. SB contributed to data collection, led on quantitative analysis, contributed to qualitative analysis, interpretation, and write-up of the paper. MCa advised and contributed to statistical analysis and write-up of the paper. RC contributed to data collection, qualitative analysis, interpretation, and write-up of the paper. AF contributed to the design of the study, data collection, analysis, interpretation, and write-up of the paper. AJ led on the literature review and contributed to interpretation and write-up of the paper. AS contributed to the design of the study, analysis, interpretation and write-up of the paper. All authors read and approved the final manuscript.

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Coffey, M., Hannigan, B., Barlow, S. et al. Recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings: a cross national comparative mixed methods study. BMC Psychiatry 19 , 115 (2019). https://doi.org/10.1186/s12888-019-2094-7

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assessment and care planning essay

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What to expect during assessment and care planning

A quick guide for people using adult social care services.

Adult care and support should help you live your life the way you want to.  

You should be treated as an individual, and your care and support should be based on what you can already do, what you want to achieve and the help you need.

People's experience in adult social care services remains the highest of priorities, and what matters most is supporting a life and not just providing a service . Clenton Farquharson, chair of Think Local, Act Personal

Making decisions

Social care staff should always involve you and respect your right to make your own decisions.

They should give you any support you need to express your views and wishes. This might include:

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Communication aids - for example, pictures, symbols, large print, Braille, hearing loops.

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Support from an advocate and/or interpreter.

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Extra time to understand the information.

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Making the conditions right to help you communicate, like reducing background noise and providing good lighting..

Staff should ask if you would like your family, friends or carers to be involved and if so, how to involve them. This is your choice and you can decide not to.

If you need support to take part in your assessment, care and support plan or review, and there is no appropriate person available to do this, you should be offered an independent advocate. You should have enough time with your advocate to prepare beforehand and to check your understanding of what has happened afterwards.

What is an advocate?

An advocate can help you express your needs and wishes, and support you to weigh up and take decisions about different options.

They can help you find services, make sure the correct procedures are followed and challenge decisions.

Your needs assessment

An assessment is a conversation about your needs, how these affect your wellbeing and what you want to be able to do in your daily life.

It should also:

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Promote your interests and independence.

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Recognise the effects of loneliness.

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Respect your dignity.

The person doing your assessment should make sure:

  • It happens at a time and place that suits you.
  • You know what the assessment is for.
  • You are given information you can understand that tells you what will happen and when.
  • You know you can bring someone with you, if you want to.
  • They have the right information about you.

After the assessment they should write down what was agreed and give a copy to you and your carer, if you are happy with this.

During the conversation you should expect:

  • To be fully involved.
  • The needs of your whole family to be considered, including your carers.
  • Any caring you do for other family members to be considered and a carer's assessment offered to you.
  • Your personal history and life story to be heard.
  • To talk about your strengths and what you want to achieve in your day-to-day life.
  • Your housing to be taken into account, including where and who you want to live with.

Care and support plan

Your care and support plan should say how your needs will be met and what your personal budget is. Your plan should be:

  • Flexible - in case your needs and wishes change.
  • Clear about how family, friends or carers will be involved in your care and support.
  • Clear how any needs you have linked to your gender, sexuality, disability, ethnicity or religion will be met.
  • Reviewed regularly - including how and when this should happen.
  • Clear about what to do if things change or there is a crisis.

man in wheelchair being handed assessment by healthcare professional cartoon

What is a personal budget?

A personal budget is the amount of money your local council says you need for your care and support. You should be given information and advice about the different ways this money can be managed and used. For example, if you have a direct payment , you will receive money regularly that you can use to arrange your own support.

Further information

  • People's experience in adult social care services: improving the experience of care and support for people using adult social care services – NICE guideline
  • Your guide to care and support: getting a needs assessment – NHS Choices
  • Carer's assessment – Carers UK
  • Care and Support Jargon Buster (Plain English definitions of the most commonly used words and phrases in health, social care and housing) – Think Local, Act Personal (TLAP) 
  • About us  - more information about Think Local, Act Personal (TLAP)
  • Paying for care  – Money Advice Service
  • Care and Support Planning Guide - National Voices

assessment and care planning essay

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  What to expect during assessment and care planning (PDF)

This content has been co-produced by NICE and the Social Care Institute for Excellence (SCIE). It is based on NICE’s guideline on   what to expect during assessment and care planning.

assessment and care planning essay

MCA: Care planning, involvement and person-centred care

This section explores two key themes that are central to care planning within the MCA framework: involvement, and keeping the wishes of the person at the centre of their care and support. It emphasises that building relationships and good communication are critical to meaningful involvement.

Involving people in decisions about them

Involving people in decisions about their care is intrinsic to the principles of the MCA and should be evident in every care and support plan. Research on mental health and wellbeing demonstrates that involvement leads to improved service outcomes and enhances mental wellbeing. [9] People who use services and their carers are experts by experience. By bringing their knowledge and ideas, they give a fresh perspective on how their particular needs for care and support can best be met.

Providers and commissioners must challenge assumptions about how care plans are developed that limit the level of active involvement by the user. Supporting people to be involved in decisions about their care and treatment should be reflected in the ethos, management, policies and care practice of each service. All services should be able to show how they do this.

Meaningful involvement is based on a sharing of power between the person using the service and the provider. Involving people in designing their care plans means:

  • having a conversation among equals who are working together to help one of them make a decision about their care and support
  • that the person is considered as a whole in all aspects of their life
  • that the plan belongs to the person, keeping them in control
  • that the plan is only implemented or shared with others if the person gives consent (where they have capacity to do so).  

These are identified [10] as key elements in person-centred care planning for people with long-term conditions. They are, however, equally applicable to care planning for all adults in need of care and support:

…care planning is a conversation between the person and the healthcare practitioner about the impact their condition has on their life, and how they can be supported to best meet their health and wellbeing needs in a whole-life way. The care plan is owned by the individual, and shared with others with their consent. It is important that a discussion takes place, there is a record of it, and people know they have a plan.

Producing a shared written record of how the person will be cared for tells them (and others whom they wish to involve) what to expect. Giving this information clearly maintains the accountability of the service provider and enables people to raise any concerns about the care plan or its delivery.

What to look for

  • The person or their family/friends are able to tell you how they were involved in developing the care and support plan and that they felt (and feel) listened to.
  • The person and their chosen representative are aware of the care and support plan and have seen a copy.
  • The care and support plan clearly explains how care and support will be delivered.

The next section considers how to create a care and support plan that follows the MCA principles.

Person-centred care and support plans

Each person’s needs and choices will be unique to them. This means that staff must do all they can to help the person convey their personal aspirations and goals, and the support they need. Creating the care plan with the person or their chosen representative will keep the focus on what is important to that individual and will enable their care and support to reflect this.

Designing an MCA-compliant care and support plan requires a cultural shift from ‘traditional’ models of care planning to  person-centred care planning . The key differences between the two are summarised in the table below (Table 1).

Table 1 Key differences between ‘traditional’ and person-centred care

Promoting involvement may mean orientating the person to the decision. For example, helping to orientate a person with dementia to the time and place relevant to the decision and filling in the gaps of their understanding. It might also include orientating a person’s beliefs concerning a decision. For example, helping someone who is depressed to hold onto positive values that were important to them when they were not so depressed. Ongoing work to reduce the effects of mental health conditions and maintain independence and control is vital to maximising a person’s capacity to make a decision.

Actively involving other people who are part of the person’s life will usually improve their care and support. Linking into a person’s existing support network will bring together all the information about them, so that their care and support are tailored to meet their specific needs and preferences. This will help to improve the user’s experience and promote their wellbeing, rather than merely responding to problems as they arise: ‘Being truly person centred is about recognising people within the full context of their lives and how they live them and not just focusing on their health conditions’. [10] The person’s wishes, thoughts and feelings should be routinely prioritised together with input from families and carers. 

What to look for in the care and support plan and other records

  • What the person would like to achieve with their care and support, their goals and aspirations for the future.
  • What is important to the person about how they live their life now: what they enjoy doing, their interests, likes and dislikes, who is important to them, who they like to see, and their preferred routines (such as when they like to get up and go to bed, whether they like a bath or a shower, etc.).
  • Details of key life events and dates to assist with chronological orientation.
  • How best to support and involve the person in decision-making.
  • Essential information for continuity of care and for use in emergencies.
  • Roles and responsibilities so that the person receives coordinated care and support to meet their needs.
  • Where a person lacks capacity to express their choices, how their families and others who are interested in their welfare have been consulted.
  • What outcome the person wants and any other options considered.
  • The associated benefits and risks of each option.

The case of M, [11] from the Court of Protection, clearly illustrates the importance of care planning that takes account of the full context of a person’s life.

Practice example: the case of M

M, a 67-year-old woman, had a mild mental health problem and lacked capacity to decide where to live. She had substantial medical needs including diabetes, which was not well controlled. M was placed in a care home by the clinical commissioning group (CCG).  It considered this to be in her best interests because of the significant risks to her health if she returned home. However, M hated living in the care home and said that she wanted to leave or she would take her own life. While acknowledging these risks, the Court of Protection said that if M remained in the care home, she was entitled to ask, what for? The right to life and the state’s obligation to protect it is not absolute and the Court must have regard to the person’s own assessment of their quality of life. In M’s case, there was little to be said for a solution that attempted to preserve her daily life without meaning or happiness.

Involvement in the cycle of care and support planning

Involvement is not an isolated activity. Ongoing communication between commissioners, providers, users and their families/carers is fundamental to taking the right decisions at the right time. It enables decisions to be altered over time to reflect people’s changing needs.

Services must make sure that their staff have the knowledge and skills to  maximise involvement  as part of an ongoing conversation that takes place at all stages of the care and support planning process. For example:

  • at the outset, when developing the plan of care for each person
  • as part of the risk management process, including safeguarding
  • each and every time care and support are provided
  • when carrying out reviews
  • through regular feedback about people’s experience of the service they receive.
  • Evidence that staff ask people about their preferences each time they provide care or support – for example, whether they want to take their medicines now, whether they would like a cup of tea, coffee or a cold drink.
  • Evidence that staff regularly ask the views of people using the service and/or their families about the care and support they receive and listen to what they say.
  • Evidence of systems for reviewing care and support plans and obtaining feedback.

Relationships

Involvement in the care and support planning cycle is underpinned by the quality of the relationship between the person using the service and the social care professional: [12] ‘People who use services have emphasized the support that they gain from relationships based on warmth, empathy, reliability and respect’. [13]

Having the right care staff with sufficient time and the right training in communication skills is critical to building effective relationships. [5]

  • Care staff talk to people in a respectful way.
  • People say that staff are caring towards them and always treat them with respect.

Communication

Assumptions are often made about the capacity of people who have limited communication skills or sensory impairments. Yet we know that it is quite possible to discern what a person feels or wants from their gestures and facial expressions, tone and volume of voice, or body language and behaviours. Care staff may need to observe a person’s responses over a period of time to understand these non-verbal signals.

A  communication chart  is a good example of a person-centred approach that carefully looks for what each individual is trying to communicate, rather than making blanket assumptions. The authors of ‘Person centred thinking with older people’ [14] provide a useful worked example about eating, based on four questions:

  • What is happening?  Food is being prepared.
  • What is the person doing?  Shutting their lips tightly.
  • What do we think this means?  Best guess – the person does not want food at the moment or wants a drink first.
  • What should we do?  Offer a drink, gently encourage the person to eat, try shifting their mealtime to later in the day, maintain a record of food consumed and monitor.

Other ways to help a person communicate include the following:

  • Making time to listen, to ask enough questions, to create opportunities for the person to tell their story in their own time, in their own way.
  • Researching their previous wishes and finding out about their values.
  • Providing all the relevant information in an accessible way – for example, in plain English, in clear writing, in Braille, in alternative languages, in pictures or in photographs, or a combination of these.
  • Using a translator or other person/professional who understands the person’s communication style best.
  • Addressing any sensory needs – does the person use a hearing aid, glasses, dentures; do they understand sign language?
  • Involving family, friends or an advocate to provide support and reassurance.
  • Choosing the right setting and time of day, considering whether the person may gain or regain capacity at a later date.
  • Meeting with the person informally to explain the options and possible outcomes.
  • Talking clearly, slowly, using straightforward, jargon-free language.

In order for care staff to successfully support people’s dignity and choices, they must do all they practically can to understand the meaning that users are trying to convey: ‘Having the power to communicate and to be understood is central to older people being able to have choice and control in their life – in fact, to have any quality of life at all’. [14]

  • A description of any communication needs and how these will be met.
  • Where the person has limited communication ability, other non-verbal communication methods that the person may use.
  • How the person was supported to be involved in decisions about their care and support.

What else to look for

  • Users have clean spectacles, dentures are fitted and hearing aids are working.
  • Staff use different communication tools to meet people’s needs.
  • Staff explain what is happening each time they offer care and support.
  • Staff take time to listen to what people are trying to convey.

5 – House of Lords (2014) ‘Select Committee on the Mental Capacity Act 2005, 2014: Post-legislative scrutiny’, summary, p 1, London: The Stationery Office.

9 – Mersey Care NHS Trust (2007) ‘Increasing mental health and well-being: Involving service users and carers’, Liverpool: Mersey Care NHS Trust.

10 – Harvey, J. (2010) ‘Key elements of personalised care planning in long term conditions and personal health budgets’, London: HSA Press.

11 – M v The County Council and the Clinical Commissioning Group (CCG) and A. EWHC 3456 (COP) (Jackson, J.) 2013.

12 – Ashead, A., Beresford, P. and Croft, C. (2007) ‘Research findings from palliative care, social work and service users: Making life possible’, London: Jessica Kingsley Publishers.

13 – Beresford, P., Bewley, C., Branfield, F., Croft, S., Fleming, J., Glynn, M. and Postle, K. (2011) ‘Supporting people: Towards a person-centred approach’, Bristol University: Policy Press.

14 – Bowers, H., Bailey, G., Sanderson, H., Easterbrook, L. and Macadam, A. (2007) ‘Person centred thinking with older people’, Cheshire: HSA Press.

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  1. Assessing the patient's needs and planning effective care

    Planning care is essential in the delivery of appropriate nursing care. Following assessment of a patient's needs, the next stage is to 'plan care' to address the actual and potential problems that have been identified. This helps to prioritise the client's needs and assists in setting person-centred goals. Planned care will change as a patient's needs change and as the nurse and/or other ...

  2. Assessing the patient's needs and planning effective care

    Abstract. Nurses have an essential role to play in the assessment and planning of patient care. This is emphasised in the Nursing and Midwifery Council's 2018 Future Nurse proficiency standards. In this article, the author discusses the importance of person-centred care in assessing needs and highlights the need for all nursing interventions to ...

  3. Assessment of needs and care planning

    According to Roper et al (2000) an assessment is a cyclical rather than once only process which includes; gathering information, assessing needs, care planning, implementing, intervention, monitoring and reviewing or evaluating. It can also be used as a way of establishing a professional relationship between the service user and practitioners.

  4. Integrating Personalized Care Planning into Primary Care: a Multiple

    INTRODUCTION. Personalized care planning, a process to collaboratively develop care plans tailored to patient priorities and social contexts, is increasingly important to providing high-quality, patient-centered care. 1 - 3 Despite varying contents and terminologies (e.g., personalized care plans, comprehensive shared care plans), these approaches incorporate common elements including (a ...

  5. Nursing Assessment and Care Planning

    A health assessment is the collection and analysis of data in order to identify the client's problems. This chapter explores the concept of health assessment, with particular reference to the nursing process, the use of integrated care pathways and the application of frameworks or models in the collection and organisation of assessment data.

  6. The Nurse's Guide to Writing a Care Plan

    Nursing team collaboration. Writing a care plan allows a team of nurses (as well as physicians, assistants, and other care providers) to access the same information, share opinions, and collaborate to provide the best possible care for the patient. Documentation and compliance. A well-written care plan allows nurses to measure the effectiveness ...

  7. Person-Centered Assessment and Care Planning

    Abstract. The quality of dementia care rendered to individuals and families is contingent upon the quality of assessment and care planning, and the degree to which those processes are person-centered. This paper provides recommendations for assessment and care planning derived from a review of the research literature.

  8. Recovery-focused mental health care planning and co-ordination in acute

    Background Involving mental health service users in planning and reviewing their care can help personalised care focused on recovery, with the aim of developing goals specific to the individual and designed to maximise achievements and social integration. We aimed to ascertain the views of service users, carers and staff in acute inpatient wards on factors that facilitated or acted as barriers ...

  9. What to expect during assessment and care planning

    Care and support plan. Your care and support plan should say how your needs will be met and what your personal budget is. Your plan should be: Flexible - in case your needs and wishes change. Clear about how family, friends or carers will be involved in your care and support.

  10. Creating a Nursing Care Plan from Case Study

    Creating a Nursing Care Plan from Case Study. Patient care planning is the organised assessment and identification of patient problems, the setting of goals, and the establishment of methods and strategies based on best evidenced based practice for achieving them (Uhlrich, Canale & Wendell, 2005). The aim of this assignment is to analyse a case ...

  11. Assessment and Care Planning in Mental Health Nursing

    Assessment and Care Planning in Mental Health Nursing. Authors: Nick Wrycraft. Published: September 2015 Pages: 232. eISBN: 9780335264759 | ISBN: 9780335264742. Open eBook. Book Description. Table of Contents. Book description: Assessment of mental health problems is a challenging area of practice that covers a range of symptoms and behaviours ...

  12. Systematic assessments of need and care planning in severe mental

    A fundamental process in community care is the construction of a care plan based upon assessment of an individual's 'needs' (Reference Brewin, Wing and Mangen Brewin et al, 1987).Normally needs are assessed by an informal process, but for research purposes standardised methods have been developed that collect data systematically using formal interview schedules (Reference Brewin, Wing and ...

  13. Assessing the patient's needs and planning effective care

    Abstract. Nurses have an essential role to play in the assessment and planning of patient care. This is emphasised in the Nursing and Midwifery Council's 2018 Future Nurse proficiency standards. In this article, the author discusses the importance of person-centred care in assessing needs and highlights the need for all nursing interventions to ...

  14. Making person-centred assessments

    Summary: The social care assessment is a 'key interaction' between a person and the local authority with 'critical' importance for determining a person's needs for care and support. In order to achieve this, the guidance requires that assessments must be 'person-centred throughout'. The concept of person-centred practice is now ...

  15. Case Study of a Care Plan for a Patient suffering multiple ...

    The nursing process consists of four stages, the assessment, planning, implementing and evaluation. This problem solving approach will be adopted to structure, organise, and present the nursing intervention. A fully detailed client's profile will be given. The "mental health assessment and plan" process will also be addressed.

  16. Making person-centred assessments

    The concept of being 'person-centred' is now well established in health and social care policy in England. Having been developed in the 1980s (O'Brien & Lyle O'Brien, 1988), it was originally established as a means of collaborative life planning in the learning disability field (Sanderson, Thompson, & Kilbane, 2006).The concept was adopted more broadly as successive New Labour ...

  17. PDF Developing Nursing Knowledge (MHN 2803) FORMATIVE ASSESSMENT

    The Assessment is a short essay on care provision and an analysis of a care plan based on a given scenario FORMAT: As part of the introduction to your short essay, describe: Care and Care Planning. Use relevant literature to support your comments (100 words) Identify TWO problems from the given scenario (BEATA) below Do a Care Plan focusing on ...

  18. MCA: Care planning, involvement and person-centred care

    Person-centred, MCA-compliant care planning. The professional assesses the person's needs. Care and support plans are developed with the person. The conversation is led by the person who knows best about their needs and preferences. Care planning follows a medical model of disability.

  19. Nursing Assessment and Care Planning

    A health assessment is the collection and analysis of data in order to identify the client's problems. This chapter explores the concept of health assessment, with particular reference to the nursing process, the use of integrated care pathways and the application of frameworks or models in the collection and organisation of assessment data.

  20. Lyubertsy

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  21. Moscow missile plant ablaze in apparent drone attack

    Moscow missile plant ablaze in apparent drone attack. Tomilinsky Electronic Plant research and production enterprise in Lyubertsy, Moscow Oblast, is reportedly ablaze after a drone attack on Sep. 1, according to our sister publication, Ukrainska Pravda. The Tomilinsky plant is under sanctions by the Ukrainian government as it manufactures ...

  22. Lyubertsy, Moscow Oblast, Russia's Internet Speeds

    This information on internet performance in Lyubertsy, Moscow Oblast, Russia is updated regularly based on Speedtest® data from millions of consumer-initiated tests taken every day.

  23. Oktyabrsky Map

    Oktyabrsky is an urban locality in Lyuberetsky District of Moscow Oblast, Russia, located 34 kilometers southeast of Moscow and 14 kilometers south of Lyubertsy.