Quality Statement 2: Individualized Care Plan - Health Quality Ontario (HQO)

Resources Quality Statements Advisory Committee About

2

Individualized Care Plan

People living with dementia and symptoms of agitation or aggression have an individualized care plan that is developed, implemented, and reviewed on a regular basis with caregivers and agreed upon by substitute decision-makers. Ongoing review and update of care plans includes documentation of behavioural symptoms and the person’s responses to interventions.

Background

An individualized care plan is essential to coordinate, document, and ultimately guide the care of people living with dementia and symptoms of agitation or aggression. The care plan is agreed upon by providers and caregivers to ensure consistent and coordinated delivery of care that considers the changing needs of people living with dementia. Ongoing review of the care plan supports the tracking of behavioural triggers and symptoms and allows for the assessment of treatment responses to interventions.

What This Quality Statement Means

For Patients

A care plan should be created to meet your individual needs. A care plan is a written statement that describes the care you receive, who provides it, and what medications you are on. It is based on your full assessment.

For Clinicians

Work with people living with dementia, their caregivers, and substitute decision-makers to create an individualized care plan that documents behavioural symptoms and responses to interventions. For people in hospital inpatient settings, review and update care plans at least once each month. For people in long-term care homes, review and update care plans at least once every 3 months. Also update care plans every time there is a significant change in people’s health or care arrangements.

For Health Services

Ensure that hospitals and long-term care homes have standardized templates for developing care plans for people living with dementia. Ensure there are systems, processes, and resources in place to create and regularly update care plans.

Quality Indicators

Process Indicator

Percentage of people living with dementia and symptoms of agitation or aggression who have an individualized care plan

Denominator: total number of people living with dementia and symptoms of agitation or aggression who have had a comprehensive assessment
Numerator: number of people in the denominator who have an individualized care plan
Data source: local data collection

Percentage of people living with dementia and symptoms of agitation or aggression who have an individualized care plan that has been implemented

Denominator: total number of people living with dementia and symptoms of agitation or aggression who have an individualized care plan
Numerator: number of people in the denominator who receive care in concordance with their individualized care plan
Data source: local data collection

Percentage of people living with dementia and symptoms of agitation or aggression who have an individualized care plan that has been reviewed on a regular basis

Denominator: total number of people living with dementia and symptoms of agitation or aggression who have an individualized care plan
Numerator: number of people in the denominator who have an individualized care plan that has been reviewed on a regular basis (at least once each month in the inpatient setting; at least once every 3 months in long-term care)
Data source: local data collection

Structural Indicator

Availability of an electronic system that captures information about individualized care plans, including the plan itself and care associated with the plan

Data source: local data collection

Definitions Used Within This Quality Statement

Reviewed on a regular basis

The care plan is reviewed at least once a month in a hospital inpatient setting and every 3 months in a long-term care setting, or sooner according to clinical need.

Caregivers

These are paid or unpaid people who help a family member, friend, or another person in need of assistance or support with daily living. In the case of a person with dementia, a caregiver may or may not also be the person’s substitute decision-maker.

Evidence to Improve Care