Individualized care plans, a practice to protect rights
Throughout history, stigma and the violation of fundamental rights have been a constant in the care provided to people with mental health problems, in all aspects of their lives. This situation leads to the denial of opportunities and social exclusion, prevents these individuals from living fulfilling lives, and is the greatest barrier to their integration into the community.
Thus, a state of exception is constructed where the invisibility of their needs and capabilities is perpetuated, both individually and collectively. Furthermore, there is a lack of access to effective, local treatments and resources, as well as strategies to develop and implement effective community care models, especially individualized and personalized care plans (ICPs) that prioritize autonomy, recovery, and social inclusion (López et al., 2008; Fisher, 2014; Salut Mental Catalunya, 2022; Corrigan and Rao, 2012).
What should we know about stigma?
Despite this, first-person activist movements are making progress in defending the rights to autonomy and freedom of choice for users of mental health services, with the promotion of personalized plans such as the Recovery and Self-Management of Well-being Manual (Sampietro, 2018). We are at a historical and social juncture in which, for the first time, changes are being implemented in institutions and policies aimed at protecting the rights of people with mental health problems, as a path towards recovery in the community (Sampietro, 2023; WHO, 2010, 2013, 2015; Ministry of Health, Social Services and Equality, 2015; EDHC, 2019).
The commitment to a community-based and recovery-oriented care model drives a new approach and strategies for the transformation of services, such as the development of individualized procedures that accept personal diversity and guarantee the right of the person to decide freely , as well as the type of resources they need (Anthony, 1993; Pilgrim, 2008; NAMI, 2014; Sampietro, 2018, 2023; Slade, 2009).
These personalized procedures or plans are closely related to the International Convention on the Rights of Persons with Disabilities (CRPD, 2006) and the empowerment of people with mental health problems (WHO, 2010), which protects the right to health, self-determination, equality, dignity and comprehensive care.
The recovery model, a paradigm shift in the approach to mental health
What is an Individualized Care Plan (ICP)?
The individualized care plan (PAI), also known as the individualized therapeutic plan (PTI), is a resource aligned with the Manual for recovery and self-management of well-being (Sampietro and Gavaldà-Castet, 2018) that belongs to and accompanies the person throughout their care process.
- It is a tool that promotes interdisciplinary teamwork and continuity of care by adapting the different health and non-health ("standardized") comprehensive support resources to each person being cared for.
- It gathers the main close references and support resources in a document integrated into the health history of the person being cared for (Somme, 2007).
- It is a fundamental instrument for the management and coordination of the care a person receives, and it is designed based on a comprehensive assessment of their needs and capabilities.
- It establishes the person's values and preferences , goals, interventions and evaluation of outcomes in all aspects of their social, physical and emotional well-being (Anthony, 1993; WHO, 2005; NICE, 2009, 2011; Health Guide, 2022).
How to develop an individualized care plan
Its implementation entails certain difficulties for professionals , among which the lack of procedural guidelines and the lack of comfort of professionals with the tool have been identified, since it is perceived more as an administrative instrument, not very academic and not clinical-care, in addition to the need for training and education for its proper use (Chamberlain and Rapp, 1991; Newcomer, 2002; Lowe, 2010).
When developing an Individualized Care Plan (ICP), there are some common errors that can be repeated, which we must address. It is important to consider some of the characteristics that an individualized care plan should have, which should be:
Multidirectional
It must start from multidirectional communication and a fluid and effective interaction between all the parties involved: the person being cared for, the professionals in charge and the family or close environment.
Feedback between parties during the PTI development process builds alliances and facilitates faster and more efficient problem-solving. Greater participation from all parties should be encouraged, leading to improved understanding and collaboration overall.
Focused on the needs of the person
Care must be person-centered and delivered by the individual, prioritizing their own goals, needs, abilities, preferences, and values . The effectiveness of a healthcare system is measured by the accessibility of comprehensive, high-quality care and the subjective experiences of those receiving it.
Healthcare professionals have an ethical and professional responsibility to provide the best possible care, regardless of any personal or work-related difficulties they may face.
Accessible and understandable for the person being served
A technical, complex, or academically dense text can hinder the understanding and effective transfer of information and fail to respect accessibility and the right to information .
Among the essential objectives of the Individualized Care Plan (ICP), it is essential to guarantee access to medical records, whether printed on paper or digitally, for both healthcare professionals and patients. These records must be presented in accessible, clear, and conversational language to avoid misinterpretation and ensure that the information communicated is understandable. Patient participation should positively impact health outcomes and the delivery of services.
Holistic and humanistic
It's not about fixing "what's broken". This stigmatizing approach is the biggest mistake in developing an ITP and suggests a limited and reductionist view of mental health problems, as it looks at the person only through the prism of their disorders, symptoms or difficulties.
Mental health care should be holistic and humanistic . with special emphasis on the value, dignity, and well-being of the person, and addressing the person as a whole, considering their physical, emotional, social, and spiritual dimensions. It must:
- Promote the development of their own coping and recovery strategies (empowerment). This involves listening to their experiences, respecting their choices, and supporting them in creating an individualized care plan that aligns with their personal values and goals.
- Identify and strengthen the person's capabilities , especially the ability to adapt to adverse situations, building skills and resources that the person can use in the long term.
- To prevent relapses and promote the person's ongoing well-being and quality of life. Mental health care should not only be reactive to a crisis, but also a tool for prevention and continuous support.
- Building support networks that include family, friends, and other community resources is essential. Mental health cannot be addressed in isolation; a person's social context and environment play a key role in their recovery.
Prepared with the participation of the person being cared for and the professionals
It's not just about giving or asking for opinions. The importance of personalized care and the active collaboration and participation of both healthcare professionals and patients in the Individualized Care Plan (ICP) empowers both parties, making them feel that their experience and perspective are valued. This can improve decision-making, treatment adherence, patient satisfaction, health outcomes, and overall service delivery.
Good practices in supporting decision-making
Much more than answering questions
A comprehensive, multidisciplinary approach is required, including prevention and coordination by the professional, active listening, offering emotional support, educating, and providing tools for self-care .
Building a bond or alliance between the professional and the person being cared for through active listening and mutual empathy, and by considering and respecting the other's opinion, can facilitate a relationship of trust and mutual respect, which is essential for the person's recovery.
Balance between protection and autonomy
It's not about prioritizing risk over protection. That is, it's important to protect people from serious risks, but constant overprotection can be counterproductive, creating dependency and a lack of self-confidence (self-esteem), and hindering the development of life skills.
A healthy balance must be found that allows both protection and personal growth with autonomy in decision-making and the ability to adapt to difficult situations.
Dynamic and proactive
It is a dynamic tool, and a passive attitude should not be adopted; rather, a proactive one is necessary. Proactivity involves acting thoughtfully while maintaining hope and a positive attitude ; even when immediate action is not possible, it should be accompanied by concrete actions and personalized plans.
Mutual support and teamwork
An individualized care plan should never be a "What about me?" kind of thing. Community mental health is a shared responsibility across different sectors and services , and everyone must contribute to the common good. Each professional and each person receiving care must also take responsibility for their own well-being in order to contribute effectively through mutual support and teamwork.
Shift lever in the care model
It's not something spontaneous or simple, and it shouldn't be a superficial or trendy exercise. An Individualized Care Plan (ICP) goes beyond treatment or intervention; it should be a catalyst for change in consolidating a recovery-based mental health care model and an indicator of the quality of care provided. It requires investing time and working together to develop and implement an ICP, which can become a person's life plan .
What should an individualized care plan contain?
Initial assessment
- Detailed information is collected about the condition of the person being cared for and their needs.
- Standardized assessment tools and clinical interviews are used.
Planning
- With the information obtained, interventions are designed and care objectives are established.
- Responsibilities are assigned to the different members of the healthcare team.
Implementation
- The planned interventions are being carried out.
- The person is provided with support and treatment as stipulated in the PTI.
Monitoring and evaluation
- The condition of the person being cared for is continuously monitored.
- The effectiveness of the interventions is evaluated and adjusted as needed.
Plan Review and Adjustment
- The PTI is reviewed and modified periodically based on the progress of the person being cared for and any changes in their condition.
Featuring
