3.7: Completion and Follow-up

David Featherston

Completing the self-management care plan

On completion of skills such as problem definition and problem solving, goal setting, action planning, psychosocial skills, emotional management, early intervention and cognitive change skills, a final document can be produced for the patient and carer; the self-management care plan. This document should be approved by the patient and signed.

Case study – completing the care plan⁽¹⁾

In this video vignette, Kelly and the psychiatrist complete the self-management care plan. They return to the issues that were raised in the Cue and Response Interview for Kelly to decide if she would like to include these in her plan, determine an intervention and clarify who is responsible for the action. The video segment looks at only two of the five issues that had been identified earlier. The self-management care plan below details the decisions made.

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Client Problem Statement: Because I lack the confidence in myself and fear being judged and rejected I avoid social situations, which makes me feel lonely and isolated.			This problem interferes with my daily activities 0 1 2 3 4 5 6 [ 7 ] 8 does not definitely severely
Client Goal/s: Arrange and go out with best friend/friends for dinner and a social activity once a fortnight.			My progress towards achieving this goal 0 1 2 3 4 5 6 7 8 complete success 50% no success

Identified issues (including self-management)	Management aims	Intervention		Who is responsible?	Date reviewed	Progress (eg no progress, some)
1. Knowledge of osteoporosis	Improve knowledge	Make contact with Arthritis Foundation		Kelly	2 weeks
2. Measuring and monitoring anorexia management	Act earlier on warning signs and make less contact with dietician	Early warning signs thermometer		Kelly, psychiatrist, dietician	2 weeks

Psychiatrist The next step is to look at the care plan and this is your care plan for you to go away with but also you can take it to other health providers, so we will review it but you can also use it with your GP or dietician or other people that might be involved in helping you manage your condition. So I will put the problem statement at the top and the goal statement as well with the ratings so that reminds you and other people what your main priorities are.

Now if we go back to the issues that we drew out of the Cue and Response, the conversation that we had the first of those was the knowledge of the osteoporosis – you thought that you might want to have a bit more knowledge about that.

Patient Yes especially in treatment and what sort of things that I can do to improve the situation, if there is anything I can do to stop it getting worse.

Psychiatrist The way that the care plan is structured is a list of your issues, your management aims, potential actions or interventions that can be part of that plan and then who’s responsible. That could be you, me, your GP a combination of those things and then a review date. Further down the track you might want to see how the progress of that is.

So with the first one, the osteoporosis the first one might be to improve your knowledge of it.

Patient Yes.

Psychiatrist Now you’ve done a lot of your own reading by the sounds of it. Now have you heard of the Arthritis Foundation?

Patient Yes but I have never actually been there and talked to anybody.

Psychiatrist My understanding is that they cover osteo, rheumatoid and osteoporosis so is that something that you would like to follow up on?

Patient That sounds like that could be really helpful.

Psychiatrist I think they have a lot of reading materials but they also have people you can talk to, people who have experience of…

Patient That would be really good.

Psychiatrist So I will put you in there as being responsible and perhaps the next time we catch up in a fortnight…

Patient That sounds fine.

Psychiatrist OK now the other big thing that I remember from our talk was this measuring and monitoring, particularly your eating disorder and the management of the symptoms. If you remember you said that you tend to get the symptoms and then contact the dietician and together you do what almost sounds like a symptom action plan. So what would be your aim that you might set, do you want to continue doing what you do currently with the dietician?

Patient I would like to be able to sort of put some more steps in place myself first to try and stop things getting worse rather than have to wait until I see her and be able to manage things.

Psychiatrist So to act earlier and, what, potentially not to make as frequent contact?

Patient Yes.

Psychiatrist Now the action or intervention for that one – it sounds like the two of you have met on a regular basis and you have probably talked through a lot of useful information. Have you ever done an early warning signs thermometer or list of your early warning signs together?

Patient No, that sounds like a good thing to do I think because that way I won’t be able to convince myself that I’m fine when I can see that things are starting to go downhill.

Psychiatrist A lot of people with mental illness have an early warning sign action plan or early warning signs thermometer or relapse prevention plan, they are called different names but essentially they are your list of things that you know which start to happen which could for you include the differences in your diet that start to happen before you start getting cold and those things so...

It is probably something that the dietician and potentially the GP could be involved in, particularly the dietician. If you want to we could actually have the three of us sit down together or contribute to that somehow?

Patient Yes, that sounds like a good plan.

Psychiatrist Well when would you like to do that or start that?

Patient Probably before we next catch up again, would be good.

Psychiatrist So if we catch up in a fortnight’s time, what I can do in the meantime is contact the dietician and see, even if we do it over the phone or if we get together or something like that. So what we are going to do is an intervention, early warning signs and that is going to be the three of us.

Follow-up and review

A follow-up plan for monitoring needs to be put in place. It is essential that early prevention is established so that the patient may avoid re-hospitalisation. It is so important that the person is kept well in the community. The patient may need to have a ‘contract’ that gives permission to the family and others to take a certain course of action, which would enable them to act should those involved notice a relapse starting to happen and the patient, because of lack of insight, not be aware of it. In NZ this is known as a ‘living will’, which should be revalidated every three to six months.

It is critical that the review asks questions which will cause the patient to feel that he/she continues to be in control of their recovery, such as:

Are you still happy with the plan we put in place?

Do you feel you might like to adjust anything?

Do you feel you might like to add something else?

Is there anything you might like to talk about or share?

In the Flinders Program it is important to attend to the tasks that have been set. As such the interview is divided into segments as follows:

Greeting and re-establishment of rapport
Identification of the issues/events that have been of most concern to the patient today
Clarification as to how the time will be spent
a. patient’s issues
b. psychiatrist’s issues
Review homework and care plan
Review medical care plan
Review outstanding issues to be addressed
Negotiate action plan and date of review

Case study – the follow-up meeting ⁽¹⁾

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Reflective exercise

The Kelly case study has shown one process for developing a self-management care plan. Jot down your thoughts on this process, identifying areas that you would definitely like to include as part of your practice.

References

Flinders Human Behaviour & Health Research Unit Self-management Program. The Flinders Model DVD.

Continue to Module 3.8: Review of Module 3