Regular review

A future care plan is a dynamic record that should be developed over time. It should be reviewed and updated as the individual's condition or personal circumstances change.

There are many opportunities to review a future care plan, such as following an admission to hospital, the diagnosis of a new medical condition, or a change in the social circumstances of an individual. We have identified the following hints and tips to help you think about reviewing future care plans:

• Ensure you have a robust process in your service to track who has a future care plan and when this needs to be reviewed. Be clear on how often this should be carried out. It is likely that this will vary between patients.
• Take a team approach. It is likely the best review will be led by the person or team who knows the patient best. Involve the whole multidisciplinary team to identify who this is.
• If you work outside general practice, for example in acute care, a hospice or in a care home, provide a summary of any future care planning conversation you have to the GP practice. Ask that the GP practice loads this information into the Key Information Summary (KIS) so that it can be shared across parts of the NHS.
• A review of an future care plan should not always be seen as a separate task. Instead think about how this can be reviewed and updated as part of provision of routine care. For example, when a practice nurse sees a patient for a chronic disease review or during an existing review of the patient.
• You might want to prioritise certain groups. Some of the following are highlighted as being particularly important to think about:
  • those living with frailty
  • people living in care homes
  • those with a chronic respiratory disease
  • people with significant mental health diagnoses
  • those approaching the end of life
  • people with advanced or progressive long term medical conditions
  • people living with dementia, and
  • patients with complex polypharmacy or multiple co-morbidities.

Healthcare Improvement Scotland has developed guidance for GP Practices on how to review and update the KIS.