Life is full of changes, and our care needs are no exception. As we go through different stages and face various challenges, it’s natural for our requirements to evolve. Whether it’s recovering from surgery, managing a chronic or long term condition, or simply adjusting to the natural ageing process, having a care plan that can adapt to these changes is crucial. Flexible and responsive care services can make all the difference in ensuring you continue to receive the support and comfort you need, no matter how your circumstances change.

 

Understanding Changing Care Needs

Changing care needs refer to the adjustments required in a person’s care plan as their health, mobility, or personal circumstances evolve over time. These changes can be temporary or permanent, depending on the situation.

 

Examples of Situations That Might Lead to a Change in Care Requirements

 

• Recovery from Surgery: After surgery, a person might need additional support during recovery, such as help with mobility or managing pain. As they recover, their care needs might decrease, leading to fewer hours of assistance.

• Progression of a Chronic Illness: Conditions like Parkinson’s disease, dementia, or diabetes can change over time. For example, someone with dementia might experience memory loss and confusion, leading to a gradual loss of cognitive awareness and an increased need for support with daily activities.

• Ageing: Ageing can lead to a gradual decline in physical and cognitive abilities, requiring more assistance with tasks like bathing, dressing, and cooking, as well as increased companionship and monitoring.

• Accidents or Injuries: An unexpected fall or injury can change a person’s ability to perform daily tasks. They might need temporary or long-term support to help them regain their strength and independence.

• Changes in Mental Health: Conditions such as depression or anxiety can impact care needs. Someone struggling with their mental health might require additional emotional support, medication management, or help maintaining a routine and encouragement to participate in activities of daily living.

• Improvement in Health: Improved health can reduce care needs. Successful rehabilitation or effective management of a chronic condition can lead to greater independence, requiring less intensive support over time.

Understanding that care needs can and do change, both increasing and decreasing, is really important for ensuring that individuals receive the appropriate level of support at all times. Being adaptable as needs change helps maintain quality of life and promotes a sense of security and well-being.

 

Communication and Collaboration

Maintaining open lines of communication between families and the care team is essential for effective care. It ensures that any changes in the individual’s condition or needs are quickly addressed.

Methods of Communication:

• Phone: Clients and families can reach out to caregivers and the care management team via phone for immediate concerns or updates.

• Email: For non-urgent matters or regular updates, email provides a convenient way to communicate.

• In-Person Meetings: Our regular three-monthly Quality Assurance (QA) and service review meetings offer an opportunity for face-to-face discussions and updates to the care plan.

 

Collaboration with Healthcare Professionals

Collaboration between all healthcare professionals involved is key to providing comprehensive care. This ensures that all aspects of the individual’s health are considered and managed effectively.

 

How Collaboration Works:

• Coordination with Doctors: Care managers work closely with the individual’s doctors to stay updated on medical treatments and recommendations.

• Nurse Involvement: Nurses may provide specialised care or monitor medical conditions that require professional oversight.

• Therapists and Specialists: Collaboration with physiotherapists, occupational therapists, and other specialists ensures that all areas of the individual’s health and well-being are addressed comprehensively.

• Integrated Care Plans: By integrating input from various healthcare professionals, the care plan becomes more holistic and effective, catering to the medical, physical, and emotional needs of the individual.

Personalised Care Plans – The Good Life Journey

Personalised care plans are essential for ensuring that each individual receives the support and assistance they need in a way that aligns with their preferences and lifestyle. These plans are designed to be flexible, adapting to the evolving needs of the individual over time.

The Good Life Journey (Our Outcomes Focused Care Model)

The Good Life Journey is an assessment, care planning and review tool which enables our Care Managers to assess, measure and plan services to support our clients in achieving their goals and aspirations.

It helps our clients and families identify key issues and the measures needed to ensure their quality of life is the best it can be.

 

The Journey is a Partnership

The Good life journey is based on an understanding that both Unique 

Senior Care, the client and their circle of care have a role in ensuring that independence is maximised and that life is as good as it can be. It is crucial that the client sees the purpose of our service as a support for them to make changes for themselves. The Good Life Journey moves away from professionals deciding what is best for a client and places the person at the centre, as an expert of their own experience.

With an emphasis on ‘doing’ with rather than ‘doing to’, person-centred care runs through both individual and group settings, allowing users of services to be active not only in their own care but also in the design and delivery of services. This approach can improve both the experience and quality of care.

 

Personalisation of Care Plans

• Initial Assessment: To create a detailed care plan, we conduct a thorough initial assessment of the individual’s physical and mental health, daily activities, communication needs, and personal preferences.

• Tailored Services:  Bespoke support is tailored to meet the individual’s needs, whether for daily activities, personal care, companionship, or specialised therapies.

• Incorporating Preferences: The care plan includes the person’s preferred routines, activities, dietary preferences, and other personal requirements to ensure comfort and satisfaction.

 

Flexibility to Adapt to Changing Needs

• Responsive Adjustments: The care plan is dynamic, allowing for quick and responsive adjustments as the individual’s needs change.

• Ongoing Monitoring:  Regular assessments and open communication allow the care team to promptly address any changes in the individual’s condition and update the care plan accordingly.

• Comprehensive Support: The flexible care plan ensures comprehensive support that evolves with the individual, providing peace of mind for both the client and their family.

Adjusting the Care Plan

Adjusting the care plan is a straightforward process to ensure the individual continues to receive appropriate care as their needs change.

Process of Adjusting a Care Plan

• Regular Reviews: During regular check-ins, Care Managers assess the individual’s current condition and discuss any observed changes or feedback from the client their family and Caregivers.

• Consultation with Healthcare Professionals:  When necessary, Care Managers will consult with doctors, nurses, or other healthcare professionals to gather additional insights and recommendations.

• Update and Implement: Based on the findings from the review and consultations, the care plan is updated to reflect the new requirements. This may involve modifying the types or frequency of services provided.

 

Examples of Adjustments

• Increasing Care Hours: If the individual’s condition worsens, scheduling additional care hours ensures they receive the necessary support throughout the day and night.

• Incorporating New Services from Other Providers: As needs change, we will integrate services from other professionals, such as physiotherapy, occupational therapy, or specialised nursing care, into the care plan.

• Rehabilitation Support:  Rehabilitation services can be integrated to aid individuals recovering from surgery or injury in their recovery process.

• Adjusting Daily Activities: Changes in mobility or cognitive function may require modifications in the assistance provided with daily activities, such as more help with bathing, dressing, or meal preparation.

By maintaining a flexible and responsive approach to care planning, we ensure that individuals receive the right level of support at all times, enhancing their quality of life and promoting their well-being.

 

Utilising Technology for Better Care

Technology plays a crucial role in enhancing the quality and responsiveness of care services. By leveraging advanced tools, we can monitor and adjust care plans more efficiently, ensuring that individuals receive timely and appropriate support. One such tool we use is CarePlanner, an advanced care management system. However, there are various other care management systems available that also provide valuable support in keeping care plans updated and responsive.

Care management systems allow caregivers to document care activities, track health metrics, and communicate effectively with the care management team.

 

How Technology Supports Effective Care

• Real-Time Updates:  These systems immediately record any changes in an individual’s condition, ensuring the care plan is always current and reflective of their needs. This real-time updating capability helps in providing prompt responses to any changes in care requirements.

• Efficient Communication: Care management systems facilitate seamless communication between caregivers, clients, families, and healthcare professionals. They ensure that everyone involved in the care process is informed and can respond quickly to any changes. This includes scheduling, logging care activities, and sharing important updates.

• Customisable Care Plans: These systems allow us to create highly personalised care plans that we can easily adjust as the individual’s needs evolve. For example, if an individual’s mobility decreases, we can add additional support immediately, or if they recover from an illness, we can reduce the level of care accordingly.

• Integrated Health Information: Care management systems can integrate various health metrics and information from different sources, providing a comprehensive view of the individual’s health. This integration supports better decision-making and ensures that care plans are holistic and well-rounded.

• Proactive Monitoring: By utilising data and feedback recorded in these systems, Care Managers can proactively monitor the individual’s health and well-being, identifying potential issues early and adjusting the care plan as needed to prevent complications.

Using care management systems enhances the efficiency and effectiveness of care delivery. They ensure the care management team receives real-time information, enabling them to review and make changes to care plans and respond to emergencies. This provides a high level of personalised and responsive care, helping maintain the quality of life and well-being of those under our care, and offering peace of mind for both clients and their families.

 

Client Involvement Strategy – Ensuring Client Satisfaction

We believe that working closely with clients, families, and stakeholders is key to delivering great care. Our clients and their families are at the heart of what we do, and their feedback and involvement help us continuously improve. By engaging with our stakeholders, we enhance the quality of our care and create a community where every voice is heard and valued. This commitment ensures that all stakeholders are central to our service, making their feedback and involvement essential to our operations.

 

Feedback Mechanisms

Ensuring client satisfaction is a top priority, and gathering feedback from clients and their families is essential. Regular feedback helps us understand what we are doing well and where we can improve to provide the best possible care.

• Regular Assessments and Check-Ins: During routine quality assurance and service review visits, Care Managers engage with clients and their families to gather verbal feedback. Care managers maintain regular contact to discuss any concerns or suggestions. Quality Assessment feedback is shared with clients and their families in the form of a ‘you said, we did’ action plan.

• Client Forums: We organise forums where clients and their families can openly discuss their experiences. These forums encourage honest and constructive dialogue, allowing clients to share feedback and suggest improvements.

• Client Surveys: We organise an annual client survey to gather feedback on the services we provide. Feedback enables us to continually improve and shape our service.

• Attending Training Programmes: we invite our clients and families to attend our training programmes to aid their knowledge and provide feedback on how we can improve.

• Newsletters: We encourage involvement in our client newsletters by dedicating a section to contributions from clients and families, including stories, testimonials, and suggestions. We highlight feedback received in quarterly meetings and the actions taken. Additionally, we invite clients and families to submit articles or topics they would like to see covered.

 

Using Feedback to Improve Services

• Analyse and Act: Feedback from assessments, check-ins, and forums is thoroughly analysed to identify trendsand areas for improvement.
• Implement Changes: Based on the feedback, we adjust care plans and service delivery. This might include changes in scheduling, introducing new services, or modifying existing practices.

• Training and Development: Feedback informs the training and development of our Caregivers, helping us enhance their skills and competencies.

• Follow-Up:  We follow up with clients and their families after implementing changes to ensure we address their concerns and maintain an ongoing dialogue.

By actively seeking and responding to feedback, we ensure that our services remain client-centred and continuously improve. This approach enhances the quality of care and builds trust and satisfaction among our clients and their families.

 

Adapting to Your Changing Care Needs

Changing care needs are a natural part of life, and it’s essential to have a flexible and responsive care plan in place. Recognising and addressing these changes ensures that individuals continue to receive the support and care they need. Our aim is to support our clients on a positive journey often towards greater independence and wellbeing; promoting person centred, strengths-based services to ensure individuals are on ‘The Good Life Journey.’

If you have any questions or concerns about your Good Life Journey care plan, are looking to get the right care in place, or if you would like to discuss how your care needs may change over time, please reach out to our expert team.