What are Comprehensive Care Plans?
Comprehensive care plans are detailed documents outlining the individualised care and services a patient requires. They are developed through a collaborative process involving the patient, healthcare professionals, and often, family members. These plans encompass various aspects such as medical needs, personal preferences, psychological support, and social factors.
Why is Using a Comprehensive Care Plan Important?
Comprehensive care plans ensure that all aspects of a patient's care are considered and addressed in a coordinated manner. This approach reduces the risk of errors, improves patient outcomes, and enhances the overall quality of care. It also ensures compliance with Action 5.14 of the NSQHS standards and Action 5.4.4 of the Strengthened Aged Care Standards.
Regulatory Requirements for Comprehensive Care Planning
National Quality Standards outline clear regulatory requirements that emphasise the need for healthcare organisations to use comprehensive care plans in service delivery effectively. These plans are essential for delivering coordinated, multidisciplinary, holistic care that aligns with patient needs and preferences.
To meet these standards, healthcare organisations need to establish effective systems, processes, training, and education to build workforce capability in using comprehensive care plans. This includes equipping staff with the skills to implement, monitor, and update these plans to ensure they remain effective and responsive to patient needs.
Relevant Standards
Action 5.14: Using the comprehensive care plan
The workforce, patients, carers and families work in partnership to:
- a) Use the comprehensive care plan to deliver care
- b) Monitor the effectiveness of the comprehensive care plan in meeting the goals of care
- c) Review and update the comprehensive care plan if it is not effective
- d) Reassess the patient’s needs if changes in diagnosis, behaviour, cognition, or mental or physical condition occur
National Safety and Quality Health Service (NSQHS) Standards
Action 5.4.4: Implementing comprehensive care plans
The provider implements processes to:
- a) deliver coordinated, multidisciplinary and holistic comprehensive care in line with the care and services plan
- b) communicate and collaborate with others involved in the older person’s care, in line with the older person’s needs and preferences
- c) facilitate access to after-hours and urgent clinical care
- d) notify the older person’s General Practitioner, families, carers and relevant health professionals when clinical incidents or changes occur.
Implementing Effective Education
Developing effective education and training follows a best-practice cycle of planning, implementation, and evaluation.
- Plan: Conduct an annual training needs assessment to align initiatives with regulatory standards. Only deliver necessary training. Schedule staggered learning to maximize engagement and avoid training fatigue and burnout.
- Implement: Deliver training and education through various modes such as online mandatory training modules, in-person sessions, especially if competency verification is required, or blended learning approaches.
- Evaluate: Use an LMS to track and report compliance, assess the effectiveness of the training plan, and incorporate improvements into the continuous improvement plan and ongoing mandatory training planning.
Assessing the Need for Training
When preparing to provide any staff training and education it’s important to identify the need, validated with evidence or data to ensure that education and training is actually the right type of initiative. Identifying the need with evidence also ensures that there’s a data point or reference to then evaluate the effectiveness of the training and education. We want to be able to assess if the education and training closed or narrowed the identified gap and delivered a positive outcome.
Here are potential triggers that may necessitate a need for training and education:
- Changes to legislation.
- Changes to internal policies and procedures.
- New compliance requirements set by regulatory bodies.
- Audits, onsite assessments and review audits.
- Internal adverse events, incidents and near-misses.
- The implementation of new products and equipment.
- Inconsistency and variation in practice.
- New patient population, condition or medicine.
- New cohort of staff who have got limited knowledge in this area.
- New funding to the organisation requiring capability-building to help meet new demands.
- Improve interprofessional communication and collaboration.
Reasons to Provide Training on Comprehensive Care Planning
A gap analysis assesses the workforce's training needs for developping comprehensive care plans, identify any skill or knowledge gaps, and determine if additional training or educational resources are necessary.
Here are some specific examples of situations that may trigger the need for training on comprehensive care planning:
- New staff: to build their understanding of organisational processes for care planning.
- In response to an audit, feedback or an incident: that reveals that staff lack sufficient knowledge or skills in comprehensive care planning.
- Changes in patient demographics: an increase in patients with complex or diverse needs requiring more complex and detailed care plans.
- New system, process or tool: to document and develop care plans may create a need for new training and education.
Example of Training: Core Components of a Comprehensive Care Plan
An effective strategy to build general workforce capability begins by ensuring clinicians have adequate knowledge of the core components of a comprehensive care plan.
The Australian Commission on Safety and Quality in Health Care has identified key components that should form the foundation of comprehensive care plans. The core components remain the same across any care plan, with the fields tailored to each person.
- Personal Identifiers and Preferences
- Clinical Assessment and Diagnoses
- Goals of Care
- Risk Screening and Assessment
- Planned Interventions
- Activities of Daily Living
- Monitoring Plans
- People Involved in Care
- Transition of Care
Additional Training Topics
Assigning the following topics could also help build the skill of comprehensive care planning:
- Communication
- Cultural safety
- Clinical assessment
- Taking a history
- Planning goals of care
- Advance care plans
- Risk screening
- Medication management
- Activities of daily living
- Improving functional status
- Nutrition
- Mobility
- Wound care
- Responding to deterioration
- Documentation
- Electronic Medical Records
Related Training Requirements
The following Training Requirements can be used to support you in building clinicians’ knowledge, skills and capability around comprehensive care plans.
Conclusion
Comprehensive care planning is a crucial focus for education and training when a need is identified. Training can address the overall process or specific components of a care plan, with additional emphasis on communication, cultural safety, and documentation to enhance staff knowledge and skills.
References and Useful Resources
- Australian Commission on Safety and Quality in Health Care, 2023. 'Comprehensive Care Standard'
- Australian Commission on Safety and Quality in Health Care, 2023. 'NSQHS Action 5.14'
- Aged Care Quality and Safety Commission, 2023. 'Stronger Standards, Better Aged Care Program - Action 5.4.4'
- Components of the comprehensive care plan
- Comprehensive care video
Author
Zoe Youl
Zoe Youl is a Critical Care Registered Nurse with over ten years of experience at Ausmed, currently as Head of Community. With expertise in critical care nursing, clinical governance, education and nursing professional development, she has built an in-depth understanding of the educational and regulatory needs of the Australian healthcare sector.
As the Accredited Provider Program Director (AP-PD) of the Ausmed Education Learning Centre, she maintains and applies accreditation frameworks in software and education. In 2024, Zoe lead the Ausmed Education Learning Centre to achieve Accreditation with Distinction for the fourth consecutive cycle with the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation. The AELC is the only Australian provider of nursing continuing professional development to receive this prestigious recognition.
Zoe holds a Master's in Nursing Management and Leadership, and her professional interests focus on evaluating the translation of continuing professional development into practice to improve learner and healthcare consumer outcomes. From 2019-2022, Zoe provided an international perspective to the workgroup established to publish the fourth edition of Nursing Professional Development Scope & Standards of Practice. Zoe was invited to be a peer reviewer for the 6th edition of the Core Curriculum for Nursing Professional Development.
