The care plan documents your care needs, goals, implementation, methods, necessary support, and the evaluation and monitoring of the care.
The starting point are your individual needs, goals and resources. Both you and and your care team have access to the care plan.
Although the attending physician has the overall responsibility for the care plan, everyone who takes part in your care shares the responsible for the planning of the plan. It is a mutual tool to ensure the continuity of care.
At its best, the care plan is flexible and adapts to the different points and situations in your life. Goals that have been met encourage both the person with diabetes and the whole care team to carry on.
The care plan must include the contact details of the attending professional so that they can also be contacted, if necessary, between the follow-up meetings agreed in advance.
Following things are recorded into the care plan:
Current situation or problem
The status of diabetes (the type of diabetes, when it was established, potential diabetes complications)
Other medical conditions
Short- and long-term goals are essential with regard to the matters related to diabetes care. The goals are mutually set. They should be realistic and set in such a way that both you and your care team are able to commit to them. Often, the way to meet a goal is via an intermediate goal.
The goals can be
Numerical, such as weight, the targeted glycated haemoglobin (HbA1c), blood sugar self-monitoring goals, blood pressure level, LDL cholesterol.
Related to your lifestyle, such as goals related to your diet, exercise, sleep pattern, alcohol use or smoking.
Daily actions related to self-management, such as the number of times you check your blood sugar level and the times of day when you do it.
The goals should be individual, concrete, challenging enough but also achievable. The goals should be reviewed on the basis of the situation and resources.
The care methods can include, for example:
The measures you have take to maintain your health and well-being, such as changing your lifestyle, peer support or taking part in an exercise group.
Using health care services, such as taking part in a weight control group.
Medication and changes to it.
Consultation with and guidance provided by a specialised worker.
The tasks related to self-management, such as the blood sugar checking plan, tracking daily steps, keeping a food diary, feet self-care.
Other methods include various learning tasks from acquiring additional information to self-management, for example.
The implementation of the care plan is assessed at the care meetings. This involves a recap of the goals that were set the previous time and analysing the degree to which the goals were met as well as the related challenges. At the same time, it can be assessed if the goals were realistic, where was succeeded and where there is still room for improvement.
The recorded things include:
Recommendation for blood sugar self-monitoring.
Recommendation for blood pressure self-monitoring.
Recommedation for the inspection of the feet and mouth health.
The next meeting, preparations for it and for example what tests are to be taken before the meeting.
