Development of Personal Plans

Assessing complex needs involves the initial development of a personal plan through a thorough evaluation of a person's specific requirements. This assessment process gathers information about the person's health status, enabling the identification of the necessary support they need. Based on this assessment, a detailed plan is formulated to outline how these support needs will be met.

Interviews

An interview refers to a communication process where a person is engaged in conversation, consulted, and asked questions regarding their health condition. This approach proves valuable in gathering essential information that might not be obtained through other means of data collection or measurement. For instance, inquiring about a person's life satisfaction can offer insights into their emotional well-being, while discussing their future concerns can shed light on their abstract thinking ability. Conducting interviews as part of the assessment not only provides valuable information about the person's preferences but also offers deeper insights into their personality, individuality and culture. Emphasising this person-centred approach to support, the interview process revolves around placing the individual at the core, encouraging their active participation, attentively listening to their needs, and acknowledging their uniqueness. Interviews can take on a formal structure with scheduled meetings or adopt a less structured format, resembling a simple conversation with the person. These interviews often occur face-to-face, although they can also be conducted over the phone or through other suitable methods.

Observations

Observations can provide valuable information about the person’s mobility and ability to function in daily life. Observational data may be gathered through standardised mobility tests or less formalised observations. As someone who sees the person most often, a support worker is usually well-placed to provide observational information.

InterRAI

InterRAI, short for International Resident Assessment Instrument, is a comprehensive clinical assessment tool utilised by trained registered nurses. This tool involves inputting information and data, which is then utilised by New Zealand aged residential care and home and community services.

As a support worker, you will not use InterRAI independently because certain aspects of the assessment require clinical judgment, which may be beyond the scope of your role.  However, you may play a crucial role in assisting the registered nurse during the assessment process. This involvement may include collecting necessary data and information for the assessment or observing any changes in the person's condition that might prompt reassessment. 

Additional assessment tools may be utilised in your workplace to gather comprehensive information. These tools can include assessments to evaluate a person's risk of falling, nutritional status, skin health, need for restraint, and more. One example is the continence assessment tool, which serves the purpose of evaluating continence issues for individuals with complex needs. This assessment covers various aspects, including toileting ability, cognitive skills, mobility, bladder and bowel patterns, nutrition, skin care, medical conditions that may cause incontinence, and the person's perspective. Any continence-related needs identified during this assessment are documented and addressed accordingly within the person's personal plan. The assessment process involves completing a checklist with questions and appropriate care options. Any necessary changes in medications must involve input from a registered nurse, continence nurse, or general practitioner, while adhering to the Code of Rights. Reassessment may be required if the person's needs change, they require new medication or experience changes in pain levels, or if significant changes occur in their bowel or bladder habits. Additionally, recording and reporting changes in the person's condition, medication, and toileting habits are essential.

Watch this video ‘What is interRAI?

Consider the benefits of using it to assess aged care clients.  

The interRAI assessment process supports clinical decision making and care planning using evidence based practice guidelines. It indicates opportunities for improvement and highlights potential areas of decline. 

The comprehensive approach and holistic view ensures that all relevant health and wellbeing information about a person can be gathered from one assessment process, rather than through a battery of individual tests.  

Read for more information about the interRAI services used in Te Whatu Ora-Health new Zealand.

The relationship between assessing a person's needs and their personal plan is integral to providing effective and person-centred care. The assessment process forms the foundation upon which the personal plan is built, as it involves a thorough examination of the individual's physical, emotional, cognitive, and social requirements. By conducting a comprehensive assessment, healthcare professionals gain insights into the person's unique challenges, strengths, and preferences. This knowledge enables them to tailor a personal plan that addresses the individual's specific needs and goals. For instance, if an elderly person is found to have mobility issues and requires assistance with activities of daily living, the assessment informs the personal plan to include measures such as physical therapy, home modifications, and support with daily tasks, ensuring a holistic approach to their care. The personal plan, derived from the assessment, serves as a roadmap for guiding the person's care journey. It outlines the specific interventions, strategies, and services that will be implemented to meet the identified needs. The plan is a dynamic document that evolves alongside the individual's changing circumstances and progress. It not only provides a clear framework for healthcare providers and caregivers but also empowers the person receiving care to actively participate in decision-making and goal-setting. The relationship between assessment and the personal plan is symbiotic, with the assessment ensuring accurate identification of needs, and the personal plan translating those needs into actionable steps that enhance the person's well-being, promote independence and ultimately improve their quality of life.

What is the meaning of contribution? In a broad context, contribution refers to giving something valuable – be it time, knowledge, skills, money, or other resources – to aid in achieving a shared goal or cause. Contribution involves offering your support to the broader personal plan process. It means you won't be solely responsible for developing, implementing, reviewing, or updating personal plans. Instead, you will utilise the knowledge and skills gained from this learning guide and within your workplace to collaborate with others as part of a team, collectively accomplishing these tasks. To actively contribute to the development of the personal plan, it is essential to grasp your role as a support worker responsible for its implementation. Understanding how you play a part in putting the person's personal plan into action after it has been devised is crucial. Familiarise yourself with your workplace's policies and procedures, as they outline the specific requirements. Additionally, consider adhering to some general guidelines that prove helpful in effectively executing the plan. By comprehending your role, following workplace policies, and applying these general principles, you can play a critical role in ensuring the successful implementation of the individual's personalised plan.

The extent of your contribution to the personal plan process for individuals with complex needs in your workplace will vary based on the following factors:

• The individuals you support
• The specific setting you work in, such as residential care or home and community
• Any existing contracts that may influence your role
• Your organisation's policies and procedures
• Your individual role and responsibilities within the team.

Common examples of tasks you might assist with include collecting relevant data, making observations, conducting interviews, and gathering feedback from the individuals and their families. It's essential to note that you are not permitted to independently perform assessments or take on tasks involving developing, implementing, reviewing, or updating personal plans. As you contribute to the personal plan process, always bear in mind your organisation's policies and procedures, as well as your designated role and responsibilities to ensure compliance and effective support.

Personal plans for people with complex needs may need to be reviewed quite often. You will learn about how and when personal plans are reviewed and what needs to happen after a review. You will then have an opportunity to reflect on your role and responsibilities in terms of reviewing and updating personal plans in your organisation.

Implementation, review, and updating of Personal Plans are critical steps in the ongoing process of providing effective and person-centred care. These stages ensure that the care and support provided remain relevant, responsive, and aligned with an individual's evolving needs, preferences, and goals.

1. Implementation

Implementation refers to putting the Personal Plan into action. It involves executing the strategies, interventions, and services outlined in the plan to address the person's identified needs. This phase requires collaboration among healthcare professionals, support workers, and the person receiving care to ensure that the plan's components are properly executed. Implementation may involve:

• Providing medical treatments, therapies, and medications as prescribed
• Assisting with activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
• Facilitating social interactions, engagement in hobbies, and community activities
• Monitoring and recording progress, changes, or challenges
• Adapting the care environment for safety and accessibility
• Communicating and coordinating with all relevant parties to ensure seamless execution.

2. Review

Regular reviews are essential to assess the effectiveness of the implemented strategies and interventions. Reviews involve evaluating whether the Personal Plan's goals are being achieved and if any adjustments or modifications are necessary. The review process may include:

• Periodic assessments of the person's physical, emotional, cognitive, and social well-being
• Gathering input from the person receiving care, family members, and involved professionals
• Analysing any changes in the person's condition, preferences, or circumstances
• Identifying areas of success and areas requiring improvement
• Considering feedback and insights from caregivers and healthcare providers.

3. Monitoring and updating

The plan of care is regularly monitored and evaluated to assess its effectiveness and to identify any areas that need to be adjusted. The person's input and feedback is important in this process. 

Updating the Personal Plan involves making necessary changes based on the review's findings. Plans should be flexible and adaptable to accommodate the person's changing needs. Updates may include:

• Modifying interventions or services to better align with the person's evolving requirements
• Setting new goals or adjusting existing ones
• Incorporating new medical information, treatments, or medications
• Altering the care environment to address safety concerns or changing mobility needs
• Revising the plan to reflect the person's preferences and choices.

Incorporating these stages ensures that the care provided remains responsive, customised, and effective over time. Regularly implementing, reviewing, and updating Personal Plans not only improves the person's quality of life but also demonstrates a commitment to providing compassionate and comprehensive care that evolves along with their needs.

Scenario: personal plan implementation, review and updating in an aged care residential home

Kody, a support worker at the "Koru Haven" aged care residential home in Napier, is responsible for caring for Mrs. Tamihana, an 82-year-old Māori resident with complex health needs. 

Implementation Phase

Kody begins her shift by reviewing Mrs. Tamihana's Personal Plan, which outlines her unique care needs. Mrs. Tamihana requires assistance with daily activities due to her declining health, which includes managing chronic pain and limited mobility causing pressure sores. The care plan also incorporates her Māori cultural preferences. 

Kody ensures Mrs. Tamihana receives her prescribed medications and assists her with activities of daily living, such as bathing, dressing, and moving around safely. She pays close attention to Mrs. Tamihana's physical health, monitoring her vital signs and any signs of discomfort. 

Throughout the day, Kody engages in conversations with Mrs. Tamihana, being mindful of her cultural values and respecting her Māori heritage.  

Review Phase

After several months, the care team acknowledges the need for a formal review of Mrs. Tamihana's Personal Plan, with a focus on her physical well-being. 

During the review, Kody, the nursing team, and Mrs. Tamihana's whanau gather to assess her physical health and comfort. They note improvements in her mobility and a reduction in chronic pain, thanks to consistent care and medical interventions. However, her sight has deteriorated and her vison is now very limited. 

They discuss her evolving physical needs, such as the need for physical therapy to maintain her mobility, adapting her environment and using technology aids to help with vision impairment. Mrs. Tamihana's whanau expresses gratitude for the care she has received and offers insights into her ongoing physical comfort. 

Update Phase

In response to the review findings, the care team updates Mrs. Tamihana's Personal Plan, with a primary focus on her physical well-being. 

They arrange for regular physical therapy sessions to help her maintain her mobility and manage chronic pain effectively. Additionally, they ensure her room is ergonomically designed to promote safety and accessibility so she can be as independent as possible. 

Throughout this process, Kody continues to provide attentive care, paying close attention to Mrs. Tamihana's comfort and independence. She maintains open communication with the nursing team and Mrs. Tamihana's whanau to address any emerging needs promptly. 

Collecting data about a person contributes to understanding their health status by providing objective, measurable information. Data may be gathered from existing health records or by speaking with, examining, observing and/or monitoring the person. The information can then be recorded and any changes over time can be monitored. Some examples of data that may be collected include:

• blood pressure
• heart rate
• weight
• skin integrity
• pain levels
• temperature
• medication
• quality of life score.

These are just some examples of the kind of data that you might be asked to collect. Depending on your role, responsibilities and workplace policies and procedures, you may or may not be permitted to gather some types of information.