My Plan: The evaluation of a person centred planning tool for people with traumatic brain injury and spinal cord injury injury

Introduction (comprising context and problem statement): People’s experience of treatment and community supports relies on tools which support person-centred planning and the integration of care. We undertook an extensive evaluation of the uptake, stakeholder use and experience of an integrated person-centred planning toolkit (My Plan) 15 months following its implementation.

Description of policy context and objective: The My Plan toolkit was designed in response to national and international developments in the disability sector. It includes a series of modules which start with a “getting to know you” period (Engage Phase) when a participant is approaching discharge from hospital. It encompasses an assessment and “getting to know you better” period (Assess Phase) which might last 3 to 4 months post discharge. This culminates in the development of a plan (Plan Phase) which articulates the participants own goals, but also identifies the contribution of family, rehabilitation team and personal assistant providers.

Target population: My Plan was designed for use with participants of the Lifetime Care and Support Authority, NSW Australia (icare lifetime care) who sustained catastrophic injury through motor vehicle crashes in NSW, Australia.

Highlights (innovation, impact and outcomes): The evaluation of My Plan involved quantitative, qualitative information, and the corroboration of information and data obtained through multiple semi-structured interviews, surveys of  all  stakeholders (participants, planning facilitators, staff),  and file reviews of My Plan modules. 

Comments on sustainability: The evaluation of the integrated person-centred planning My Plan toolkit confirmed participants and families view planning and the My Plan approach positively and the planning facilitators and Lifetime care staff consider the toolkit of value and enables a flexible approach to planning for integrated care. My Plan has changed the focus of planning away from a therapy directed planning process to a person-centred approach to goal setting and supports.  A total of 853 participants were supported and completed a My Plan completed and a total of 1,381 My Plans were received by icare lifetime care.

Comments on transferability: My Plan is used with participants of all ages, injury types, locations, severities and duration post injury. Future work involves using My Plan with people catastrophically injured at work and others with chronic dust diseases such as mesothelioma through exposure at work. 

Conclusions (comprising key findings, discussion and lessons learned): The presentation outlines evaluation methods, key findings, trends and emerging implications for stakeholders (including participants, planning facilitators, providers and icare lifetime care). Best practice and holistic integrated care planning is illustrated through examples of plans.