title: Care plans and care planning in long-term conditions: a conceptual model.
abstract: The prevalence and impact of long-term conditions continues to rise. Care planning for people with long-term conditions has been a policy priority for chronic disease management in a number of health-care systems. However, patients and providers appear unclear about the formulation and implementation of care planning. Further work in this area is therefore required to inform the development, implementation and evaluation of future care planning initiatives. We distinguish between 'care planning' (the process by which health-care professionals and patients discuss, agree and review an action plan to achieve the goals or behaviour change of most relevance and concern to the patient) and a 'care plan' (a written document recording the outcome of a care planning process). We propose a typology of care planning and care plans with three core dimensions: perspective (patient or professional), scope (a focus on goals or on behaviours) and networks (confined to the professional-patient dyad or extending to the entire care network). In addition, we draw on psychological models of mediation and moderation to outline potential mechanisms through which care planning and care plans may lead to improved outcomes for both patients and the wider health-care system. The proposed typology of care planning and care plans offered here, along with the model of the process by which care planning may influence outcomes, provide a useful framework for future policy developments and evaluations. Empirical work is required to explore the degree to which current care planning approaches and care plans can be described according to these dimensions, and the factors that determine which types of patients and professionals use which type of care plans.
authors.affiliation: 1Cambridge Centre for Health Services Research,Institute of Public Health,University of Cambridge,Cambridge,UK.
authors.forename: Jenni
authors.initials: J
authors.lastname: Burt
authors.affiliation: 2National Institute for Health Research School for Primary Care Research,Manchester Academic Health Science Centre,Centre for Primary Care,Institute of Population Health,University of Manchester,Manchester,UK.
authors.forename: Jo
authors.initials: J
authors.lastname: Rick
authors.affiliation: 2National Institute for Health Research School for Primary Care Research,Manchester Academic Health Science Centre,Centre for Primary Care,Institute of Population Health,University of Manchester,Manchester,UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Blakeman
authors.affiliation: 3Research Institute for Primary Care and Health Sciences,Arthritis Research UK Primary Care Centre,Keele University,Keele,Staffordshire,UK.
authors.forename: Joanne
authors.initials: J
authors.lastname: Protheroe
authors.affiliation: 1Cambridge Centre for Health Services Research,Institute of Public Health,University of Cambridge,Cambridge,UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Roland
authors.affiliation: 2National Institute for Health Research School for Primary Care Research,Manchester Academic Health Science Centre,Centre for Primary Care,Institute of Population Health,University of Manchester,Manchester,UK.
authors.forename: Pete
authors.initials: P
authors.lastname: Bower
mesh_terms: D002908:Chronic Disease; D003657:Decision Making; D004739:England; D006291:Health Policy; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration*; D008962:Models, Theoretical; D010347:Patient Care Planning / Q000458:organization & administration*; D010817:Physician-Patient Relations; D011320:Primary Health Care / Q000458:organization & administration*