Quality Statement 3: Individualized Care Plan - Health Quality Ontario (HQO)

Resources Quality Statements Advisory Committee About

Individualized Care Plan

People living with dementia have an individualized care plan that guides their care. The plan identifies their individual needs, those of their caregivers, and goals of care. The plan is reviewed and updated on a regular basis, including documentation of changing needs and goals and the person’s response to interventions.

Background

An individualized care plan is essential to coordinate, document, and ultimately guide the care of people living with dementia. The care plan is developed by and implemented in collaboration with the person living with dementia, caregivers, and providers to ensure consistent and coordinated delivery of care that considers the changing needs, goals, values, and preferences of people living with dementia. Care plans need to be communicated to and accessible to the person living with dementia, members of the interprofessional care team, and caregiver or substitute decision-maker. Ongoing review of the care plan supports revisiting goals of care and allows for the reassessment of evolving needs, preferences and the person’s treatment responses to interventions.

Older adults living with dementia are at high risk for adverse drug events. Medication optimization is an important aspect of care for people living with dementia. Considerations include medication adherence, appropriate treatment targets for comorbid conditions (e.g., hypertension, diabetes), appropriate use and monitoring of cognition-enhancing medications (e.g., donepezil, galantamine, rivastigmine, memantine, and optimized use of medications with potentially adverse cognitive effects (e.g., minimizing to the lowest dose necessary or eliminating all inappropriate or unnecessary use of medications including, but not limited to, anticholinergic drugs, benzodiazepines and other sedative-hypnotics, antipsychotics, and opioids). The decision to continue or discontinue a medication should be individualized and based on regular reassessment of both benefits and harms.

What This Quality Statement Means

For People Living With Dementia

You, your caregivers, and your health care team should create a care plan together that reflects your needs, concerns, and preferences. A care plan is a written document that describes your goals, the care and support services you should receive, and who will provide them. It should be updated regularly, especially if there is a change in your health or situation.

For Clinicians

Work with people living with dementia and their caregivers to create an individualized care plan that documents care and services and responses to interventions. Review and update care plans every 6 to 12 months, or sooner if there is a considerable change in a person’s health or care arrangements.

For Health Services

Ensure there are systems, processes, and resources in place to support clinicians to develop and regularly update individualized care plans, as well as to communicate care plans to others who provide care to the individual. Resources may include standardized care plan templates.

Quality Indicators

Process Indicators

Percentage of people living with dementia who have an individualized care plan that guides their care

Denominator: number of people living with dementia
Numerator: number of people in the denominator who have an individualized care plan that guides their care
Data source: local data collection

Percentage of people living with dementia who have an individualized care plan that is reviewed annually

Denominator: number of people living with dementia who have an individualized care plan
Numerator: number of people in the denominator who have an individualized care plan that is reviewed annually
Data source: local data collection

Definitions Used Within This Quality Statement

Individualized care plan

This is a plan based on an assessment of the life history, social and family circumstances, and preferences and needs of the person living with dementia. It is also based on their physical and mental health needs and current level of functioning and abilities. Developed and reviewed with the person living with dementia and their caregiver, the care plan should be flexible, to accommodate changes in the person’s health status, function and abilities. The plan should include the following components:

The results of the comprehensive assessment (see Quality Statement 1)
The person’s individual needs, preferences, and goals of care, and those of their caregiver
A plan to minimize relocations and retain a familiar living environment for as long as possible
Assessment and care-planning advice about activities of daily living and instrumental activities of daily living
Details of environmental modifications to help the person function independently and to promote safety; these can include assistive devices and technologies, if available (see Quality Statement 9)
A plan for physical exercise, with an assessment and advice from a physiotherapist or occupational therapist, when needed
Support for people to participate in meaningful activities at their own pace
Individualized nonpharmacological and pharmacological interventions, as indicated
A plan for managing behavioural symptoms associated with dementia, if present
A nutrition care plan
A safety plan, including crisis and emergency management
Advance care planning includes the capable person living with dementia confirming a future substitute decision-maker (see Terminology Used in This Quality Standard for a more detailed description) who can communicate their wishes, values, and beliefs about future health care, and make care and treatment decisions when that person is no longer mentally capable of doing this for themself. (For more information on advance care planning, please refer to Health Quality Ontario’s quality standard on palliative care: Palliative Care: Care for Adults with a Progressive, Life-Limiting Illness.)
At least one named point of contact on the care team—this is the provider who facilitates care coordination and transitions across settings for the person living with dementia (see Quality Statement 4)

Regular basis

The care plan should be reviewed every 6 to 12 months, or sooner according to clinical need. Reviewing the care plan may require a partial or full reassessment, including revisiting the goals of care with the person and caregiver.

Evidence to Improve Care