Developing a care plan which works towards delivery of patient-centred goals

The Proactive Healthcare for Older People in Care Homes (PEACH) study considered how to deliver high quality care to older people living in UK Care homes.  Here Neil Chadborn, Claire Goodman and Adam Gordon discuss the findings of a realist synthesis on how Comprehensive Geriatric Assessment works in care homes.  This is the third of three blog posts on the subject, completing the description of how Comprehensive Geriatric Assessment works in this setting.

Neil Chadborn is a Research Fellow in the Faculty of Medicine & Health Sciences at University of Nottingham; he tweets as @nchadborn

Component 3 – Working towards the delivery of patient-centred goals

In this part of the process, actions from multidisciplinary care plans are put into practice.  This part was not developed or discussed much within the research.  There was very little evidence about how staff accessed information from needs assessments and care plans, or how they used them to improve care over time.  The focus was on assessment.

More improvement work is required to provide the detail of how care plans are communicated to all care practitioners, leading to coordination of care delivery. Who is best placed to implement the care plan and what needs to be in place to make this happen was not discussed in the literature.

Our broader understanding of best practice suggests the following recommendations:

  • Teams should give careful thought to how the outputs of multidisciplinary assessment and care planning are documented and shared.
  • Time needs to be set aside to agree how the priorities identified in the care plan will influence the actions of both care staff and health professionals. The findings of assessment must be both seen and actioned.

We found that some forms of Comprehensive Geriatric Assessment in care homes were able to change patterns of prescribing, to reduce readmission rates to hospital and to increase rates of appropriate referral to allied health professionals and palliative care teams.

We conclude that Comprehensive Geriatric Assessment can work in care homes and that it can make a difference to resident care.  Preparation and planning is required to support assessment of residents by multiple professionals, to provide a mechanism to draw the findings of assessments together, to include an appropriate mix of professionals in care planning, and to ensure the actions identified in a care plan are carried out.  This may be more complex in care homes than in other settings but the recommendations over our series of blog posts highlight important areas for attention.

More about the PEACH study and see the realist synthesis in greater detail at: https://bmjopen.bmj.com/content/9/4/e026921.info

To hear more about the project, please do come to our 2019 annual lecture where Adam Gordon will be presenting the findings.