How to Set Up a Complex Care Plan

06 July 2023

When a person has complex healthcare needs they must have an appropriate care plan in place. This is to ensure that their condition is managed correctly and the best support is provided so they can live a dignified and fulfilling life. Our Nurse Case Managers take a strengths-based collaborative approach to care planning with our clients and this forms the cornerstone of all care delivered by our expert complex care teams.

What is a complex care plan?

Complex care is the specialised ongoing care of people who have a chronic or long-term health condition or disability. This type of care can encompass a whole range of clinical, social, and emotional support for the person and their family members.

As part of a comprehensive complex care package, a detailed and individualised care plan will be set up by clinical healthcare professionals. It will then be delivered by experienced nurse-led carers, highly trained in the needs of each client and their specific condition.

Expert complex care can be necessary for individuals with a variety of conditions including:

● Spinal injury

● Brain injury

● Neurological conditions such as MND, MS, MD, CP

● Strokes

● Respiratory care (invasive and non-invasive ventilation)

● Airway management (tracheostomy care)

● Oxygen therapy and monitoring

● Epilepsy and seizure management

What are the steps of setting up a complex care plan?

The first step of setting up a complex care plan is the initial assessment of a client’s unique needs. This is to make sure they transition home from hospital in a safe and supported manner. The assessment will look at a client’s current health condition, taking into consideration potential risk factors or issues that could arise with in-home care.

As an established complex care provider, we work in partnership with NHS Continuing Healthcare commissioning teams and other clinical professionals that form the wider Multi-Disciplinary Team (MDT) around a client. As a result, our complex care plans reflect the same evaluation processes that the NHS uses to assess an individual’s care requirements. Our comprehensive assessment which sets out the requirements for a person-centred care plan, contains 13 care domains to ensure a complete picture of our client’s care needs. These domains are; Breathing, Nutrition – Food and Drink, Continence, Skin, Mobility, Communication, Altered States of Consciousness (ASC), Psychological and Emotional Needs, Cognition, Behaviour, Drug Therapies and Medication and any other significant care needs.

A thorough assessment and complex care plan, enables the appropriate health equipment to be provided along with preparing the client and their family members for what lies ahead in their care journey. A dedicated care team will then be specially selected to best meet the client’s needs.

When putting together a complex care package, our expert health professionals will get to know the client and understand the challenges they face. The care plan will take a holistic approach, considering every aspect of an individual’s needs. This includes their physical health, mental well-being, and personal boundaries. Along with their goals and ambitions both in terms of their rehabilitation and day-to-day life.

Women in wheelchair and her caring having a friendly chat

The next step of a complex care plan is a well-structured care routine. This helps a client transition to in-home care in the most comfortable and stress-free way possible. An appropriate care routine will consider every aspect of a client’s needs. This can include making sure medicine is properly administered with the correct dosage and following the best practices for clients that require highly specialised procedures like tracheostomy care. Ensuring a client’s care is well organised helps them in achieving their rehabilitation goals and integration back into the community, giving clients a sense of autonomy over their condition and improving their overall well-being.

The last step of a care plan is to make sure it is consistently reviewed. Throughout a client’s care, we work closely with them and their family to establish the best care plan for their individual and evolving needs. Our specialist nurses complete regular competency assessments of all our in-house care teams to ensure they meet the highest standard of care.

What are the benefits of a comprehensive complex care plan?

Living with a complex health condition can be stressful both for a client and their family members. But when the right care plan is in place, it can give clients and their families the reassurance they need. Giving them confidence they are in safe hands and their care is being managed in a professional and compassionate way, with all circumstances and conditions being taken into consideration with every decision that is being made.

A well-structured and considered care plan will ensure that a client’s health condition is overseen correctly, meaning fewer complications that can negatively affect a client’s health journey and can lead to preventable hospital visits that cause extreme worry and distress.

Our outcome-focused complex care plans help clients attain a sense of achievement and confidence. Whether they are going through rehabilitation or simply learning to live with their condition in the best way possible. Having a comprehensive care plan helps clients to thrive.

At HFH we offer the very best in nurse-led complex care plans to suit our clients’ individual needs, ensuring they get the best support for both their physical health and mental well-being.

If you would like to find out more about our complex care services we provide please call us on 0208 605 9714 or email Alternatively, if you are looking to join our dedicated care team please browse our vacancies here.

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