Care Planning Assessments Models and Tools in Health and Social Care


Complexity is rising in the current health setting due to the number of treatment centers and specialists engaged. Therefore, a thorough multidisciplinary description of client health concerns and planned action is required to ensure safety and continuity of care. Care planning may occur during team meetings, but choices are not always fully documented. Furthermore, various experts utilize diverse documentation formats, frameworks, and languages to describe their evaluation, goals, and planned intervention. The importance of optimal care planning in supporting patient-centered care and preventing routine treatment has been emphasized. Patient-centered care is a care philosophy that prioritizes the client’s concerns in designing care practices and support services (Kazak et al., 2017). Respect for patients’ beliefs, preferences, and expressed requirements, as well as shared choices between clients and care providers, are some essential components of patient-centered care that health facilities should consider. It is vital to create a model of care planning that depicts the interplay of organizational, process, and outcome factors and how they work together to improve quality performance.

The Donabedian Model

The model differentiates between structural aspects, such as administrative approaches and the physical and social environment, influencing health outcomes. Process variables are the actions that are carried out to improve the client’s condition (Tossaint-Schoenmakers et al., 2021). In this perspective, structural factors such as architectural design play an essential role in promoting clients’ health and well-being. The model aims to incorporate structural and process planning to understand how they influence the quality of care and patient health (Tossaint-Schoenmakers et al., 2021). It is founded on the belief that assessing a patient’s health requirements is necessary before providing a thorough diagnosis and developing plans for different care measures.

The client’s health condition serves as the foundation for all care efforts. The client comes to the health facility with a specific perceived health status, which arises from the difference between the client’s actual and expected health condition. The client’s health gap will close as treatment quality and intervention increase. It is theorized that as more initiative is incurred to retrieve information about the client’s health needs, the effectiveness of the assessment plan will strengthen, leading to a more reputable diagnosis (Tossaint-Schoenmakers et al., 2021). Consequently, the quality of the intervention improves, facilitating the client’s health progress; for instance, in one scenario, a patient allergic to penicillin reports at the hospital with signs of upper respiratory infections. The health care team, particularly the nurses, must undertake a detailed prior medical history of the client, including an evaluation of the right drugs suitable for treating the patient. A good history-taking and evaluation will result in a proper diagnosis, ensuring that a definitive plan of action and interventions are performed for the client.

Communication improves assessment performance and the capacity to discuss choices with the client. An improvement in communication with the client will enhance the quality of the assessment, which will boost the precision of making a diagnosis and the execution of the care treatments, ultimately improving the client’s health. Furthermore, enhanced communication enables contact and cooperation with the patient, hence the ability to share care decisions. Ultimately the culture in the hospital setting plays a significant role in the performance of the care planning approach. The dominant attitudes, ideas, and assumptions around care are determined by culture. Professionals must have clearly defined and agreed-on goals to operate effectively. According to Karamitri et al. (2017), cultural variables like a learning institution, a patient-centered mindset, and continuous education can aid in organizational quality development. A strong culture can define the basic concepts of care and humanity (Karamitri et al., 2017). A great culture respects individual employees and patients while encouraging cooperation and interpersonal interactions.

Care Planning Policies

Advanced Directive policy

This policy is intended to foster a respectful and compassionate environment while also ensuring that each client’s capacity and ability to engage in medical decision-making is upheld. The hospital policy is to respect and foster patient autonomy (Enguidanos & Ailshire, 2017). Through training, inquiry, and help, if needed, clients will be motivated and supported to be full contributors to the decision-making process. An out-of-hospital Do Not Resuscitate (DNR) is an example of an advanced directive, a signed document between the patient or a patient’s representative with the physician. The document encourages medical workers working in and out of hospitals not to maintain life-sustaining interventions such as cardiac resuscitation, defibrillation, and artificial airway ventilation. This, on the other hand, does not include the suspension or delaying of medical procedures or therapies deemed essential to provide comfort care, reduce pain, or supply water and nourishment.

Healthcare professionals should empower and support patients who require palliative care or DNR. This is a role that nurses are well-known for doing successfully. These patients, for example, require patient-centered medical homes that necessitate care coordination between the patient and caregivers. According to recent research, financial incentives for clinicians and clients have been enhanced to encourage patient-centered medical home efforts (Qureshi et al., 2020). Financial assistance and support have been made available to providers to help them establish patient-centered nursing homes.

Competency Assessment Policy

Competency is defined as the specification of abilities and expertise and their execution to a specified level of performance expected at work. It includes the capacity for skill and information transfer and application to diverse settings and locations. Healthcare workers are expected to uphold a high competency standard in managing different conditions (Cruz, 2017). On the other hand, assessment is the technique of gathering information and making judgments about the degree and character of a patient’s illness based on the signs and symptoms.

Nurses and physicians should take both subjective and objective data since it is critical for the successful application of competency standards in the hospital setting. When nurses do an assessment of a client, they may uncover an issue that necessitates the assistance of other professionals in the hospital (Cruz, 2017). Throughout therapy, nurses will visit clients more regularly than physicians, and they will protect patient safety. For instance, prior to administering methadone, the nurse should confirm that the client is awake and aware, is not under the effect of any other substance, and seems to be in excellent overall physical health. If the nurse does not conduct an effective assessment of the patient prior to medicine delivery, substantial complications to the client’s health can occur, including adverse pharmaceutical responses and methadone overdose, which can be fatal. Thus, nurses working in methadone clinics must be vigilant about developing an assessment routine with each and every patient they meet.

Monitoring and Review of Processes Related to Care Planning

The care planning process is divided into four significant steps. The stages can be followed sequentially with a patient to build a treatment plan in one-on-one contact with the client and then monitored via follow-up. On the other hand, a care plan may be produced iteratively during a series of patient visits, frequently with the participation of many healthcare professionals. This enhances new information about the client while revising the plan together (MacKenzie et al., 2018). Finally, the plan of care is a document that is constantly revised in collaboration with the patient when new information becomes accessible, such as through client follow-ups or evaluations performed by other healthcare practitioners.

The first phase in the planning of care is identity. It consists of a comprehensive, personalized care plan with the client in an intense adoption of collaborative goals and a joint decision-making process. It is usually only conducted for clients within a practitioner’s practice who need additional time and work to help them manage their chronic health issues (MacKenzie et al., 2018). It is often done to increase patient self-management, interaction, and collaboration among numerous healthcare practitioners, or both. In this case, the practitioner must preserve the principle of autonomy, which allows the patient to make their own decisions. At the same time, the nurse or clinician assists them in putting them into action. The identity phase entails defining the general objectives for care planning, such as enhanced care coordination, increased client self-management, or both. Furthermore, it reviews the outcomes planning of care regularly to evaluate if the standards for recognizing clients need to be modified.

The second phase is preparation, and here care planning occurs at a different session since there is ample opportunity to gather all pertinent information for the care planning meeting with the patient. A team representative frequently performs preparation to maximize the clinician’s time with the client. The team representative creates an interim medical treatment plan, when appropriate, with the use of clinical decision support technologies. This may involve establishing objectives for the problems of interest, recommending screening, medication, monitoring, and recommending referrals to other colleagues or specialists.

The third phase is the planning of care together with the patient. In most teams’ descriptions, the patient’s real care planning interaction is depicted as a fluid, not necessarily sequential, process. If the client’s information has already been collected or verified prior to the visit, or if other evaluations have already been performed, some tasks may not be required. But a few steps are essential to a collaborative process: generating common understanding, defining objectives together, formulating a plan for the client and healthcare team together, and validating shared understanding (MacKenzie et al., 2018). The process of developing a new management plan for a client differs from the process of revising an existing one.

At this stage, the nurses need to put into practice the policy of fidelity. The moral principle of fidelity instructs nurses to demonstrate care delivery in a loyal, compassionate, and honest manner. For instance, an ethical issue can arise when terminally ill elderly patient refuses to tell their immediate family that they have a terminal disease. It is imperative not to share any medical details without the patient’s permission to keep the nurse-patient partnership confident. Caregivers, clergy, and social workers can all be members of an interdisciplinary group that helps identify the types of services that a client might require as their disease progresses.

The last phase involves the management of the patient and follow-up care. Recommendations for closing the cycle of care planning are particularly encouraged. The therapeutic action and follow-up plan dictate the tasks in the management phase. It is essential to keep the treatment plan up-to-date and flexible to be updated when new information comes to light in an ongoing dialogue with the patient (MacKenzie et al., 2018). This document should be examined at every patient encounter or visit. It is essential that the patient’s treatment plan be reviewed and revised regularly. It is imperative that nurses adhere to the nonmaleficence policy of only performing treatments that will positively impact the patient’s health. For instance, a nurse’s obligation to protect the public may conflict with the desire to protect the privacy of a patient who has homicidal thoughts and a definite plan for executing them, as in this case. The nonmaleficence principle infers that nurses should prioritize the health and well-being of clients and the community in any healthcare setting.


The planning of care is a complex dynamic process to analyze the effects of different variables on the outcome. Using the Donabedian concept is a good way to explore and communicate complicated concepts concerning healthcare procedures. A theoretical basis for future research into the specific care planning process has been established through the development of the model. According to the model, the health outcome of a client is influenced by the socio-cultural environment of the hospital. Ultimately, patient care planning in this diverse and complex environment of care delivery is clinically relevant. Aging populations are connected with a number of health risks, and insufficient evaluation may result in the loss of a chance to diagnose a potentially fatal condition.


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Tossaint-Schoenmakers, R., Versluis, A., Chavannes, N., Talboom-Kamp, E., & Kasteleyn, M. (2021). The challenge of integrating eHealth into health care: systematic literature review of the donabedian model of structure, process, and outcome. Journal of Medical Internet Research, 23(5), e27180. Web.

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