Care Plans/Health assessments

Mental Health Care plan

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Care Plan - Chronic Disease Management

In general practice a care plan is “a process for setting and achieving goals”. This involves: Assessment of the patient’s condition/s in relation to overall health and functionality outlining the practitioner’s goals for the patient addressing the patient/carer’s needs and goals Planning treatments and actions which will meet the goals, and planning review steps. If the GP involves other health and care professionals, the plan will also include: collaboration between providers to prepare the plan recording of each party’s goals and the treatment/care planned to meet those goals, and regular review of the team arrangements.

Team Care Arrangement

A Team Care Arrangement (TCA) is a plan prepared by a GP in collaboration with other services, for a patient of any age who has one or more chronic conditions and who would benefit from multidisciplinary care. For instance, where routine management is compounded by unstable or deteriorating condition, increasing frailty or dependence, development of complications, comorbidities or a change in social circumstance. The TCA outlines the goals, care and services which the multidisciplinary team agree on together, with the consent of the client. It includes the client’s contribution, as above. The team must comprise at least 3 health or care providers .

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