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Complex care management and care planning

Understanding complex care management and care planning

Complex care requires careful management and forward planning in order for carers and family members to remain proactive with a person’s health and care needs. Whether or not you or your loved one have already had a Care Plan put in place, organising care for a person with complex needs often means further care planning is required. 

Here, we are looking at what makes the complex care plan different from other home care plans, what to expect in a Care Needs Assessment and how this differs for complex care, home adaptations needed for complex care, how to manage transitions from hospital to home, and how carers and medical staff can work together to support someone with complex needs. 

At Home Instead, our aim is to help people age positively and in place by bringing expert care to their home. For nearly 20 years, we have been providing the highest standard of care, and creating industry-leading training programmes for our Care Professionals that are accredited by nursing and medical professionals. Today, we are the world’s largest global domiciliary care network, supporting over 100,000 older adults with personalised, tailored care at home. So whatever questions you have about complex care at home, we can help. 

What is complex care? 

Complex care is a type of person-centred care for anyone living with a chronic or long-term health condition who needs additional help to manage daily symptoms and continue with activities they enjoy. Any condition requiring a combination of treatments and support could qualify as complex care, such as a neurological condition (for example, a stroke or dementia), a mental health issue requiring help for severe symptoms (for example, bipolar disorder or schizophrenia), or an injury requiring a long recovery, physiotherapy, and help at home. 

You may find more useful information about complex care in some of our other guides:

Complex care differs from other types of home care as it typically involves elements of medical or nursing care too. A few examples of complex needs include: 

These are only a few of the complex care needs someone might have, and some people live with multiple conditions requiring more help. In these cases, the careful management of complex care and forward care planning is incredibly important to ensure an excellent standard of care, as well as the person’s comfort and safety.

complex care management

What is a complex care plan, and how does it differ from a regular care plan?

A Care Plan is a written document created for anyone who is eligible for care. This document details information about the type of support needed to meet the care needs of the person, and allows everyone involved – from local authority staff, to private carers, to family – access to information about the person’s needs. According to the NHS, a Care Plan should include:

  • The person’s own preferences and priorities 
  • What they can do themselves 
  • What equipment or care they need
  • What their friends and family think they need 
  • Who to contact if they have questions about care
  • Their care budget and direct payments (weekly totals the council will spend on care)
  • What care they can get from their local council
  • How and when care will happen

As well as the above, every Care Plan is personalised to the person’s own needs, so some additional inclusions might be information on things like: 

  • Adaptations needed to make the home safe and comfortable
  • The carers involved and how often they visit 
  • Contact numbers for out-of-hours care (if applicable)
  • Information on respite care requirements 
  • The person’s individual preferences for care and their living situation 
  • The person’s individual desires for socialisation and community activities 

All Care Plans are unique to the person, but the National Institute for Health and Care Excellence states that all plans should include extensive information on how a person’s needs will be met. The point of any Care Plan is to clarify the roles and responsibilities of each person involved in care. 

Complex care plans are similar to other care plans, but often include slightly more information on the medical care side as typically there will be an element of medical care involved to address the multiple needs of the individual. A complex care plan will integrate medical, social, psychological and environmental factors to create a coordinated, holistic approach, and encourage collaboration between various healthcare professionals, caregivers and community resources. 

Research finds that complex care can sometimes lack consistency and clarification, so a Care Plan is incredibly important for those with complex care as it includes information about every health and social care professional involved, a summary of the person’s health status, plans for their future care, any care coordination efforts made to improve quality of care, the patient’s own responsibilities during care, and more. 

The complex care plan should be reviewed and updated regularly as needed, written in simple language so non-medical staff can understand it, and displayed prominently in the person’s home so they can find the information they need at any time. 

A complex care plan gives people the opportunity to be part of the planning process, decide any goals they would like to aim for, help them feel better about any long-term conditions they live with, and learn how to manage these more effectively. Complex care plans can help people feel more confident and in control of their own health by ensuring they understand the care required – this is the essence of person-centred care. 

You can find more information on general Care Plans in our guide: All About The Care Plan.

What happens in a Care Needs Assessment for complex care?

A Care Needs Assessment is an assessment carried out to discover what an individual needs for their health-related care and social support. Assessments are undertaken by an independent assessor who will consider a person’s physical, mental and emotional needs, as well as what care could be implemented to manage these. A Care Needs Assessment may take into account things like a person’s mobility needs, their communication needs, their personal care needs, and any medical conditions they have. 

In the case of a person with complex needs, a Care Needs Assessment will take a more tailored, comprehensive look at their needs and goals to evaluate the individual’s medical, social, psychological and environmental requirements for care. This is usually done by gathering detailed information about any health conditions present, disabilities, the person’s functional abilities, and the support network available to help. 

A Care Needs Assessment for complex care would typically involve steps such as:

  • Organising an initial assessment – the person or their current caregiver will be contacted to let them know when someone will be in touch. This could initially be a phone or face-to-face assessment depending on the needs of the person. 
  • An in-person assessment – The initial consultation should aim to gain more information so that the relevant assessor can be chosen. This should be someone with appropriate training and experience in the type of complex care being evaluated. Once an appropriate assessor has been selected, they will visit the person’s home. 
  • Home evaluation – In most assessments an assessor will walk around the home to examine whether or not any changes should be made to cater to the specific complex needs of the person. 
  • Discussion – The assessor will discuss with the person and their family or caregivers what their daily activities look like, how they are managing at the moment, the health conditions affecting their life, and any personal preferences they have for their care. This discussion should provide an overview of the person’s functional abilities, cognitive abilities, social support system, environmental challenges, mental health needs, and more. 
  • Creation of the Care Plan – After the assessment is complete, the assessor will create a Care Plan alongside any healthcare professionals, caregivers and recommended community resources. 

The Care Needs Assessment is a similar process for everyone, however for those with complex needs, usually this will require an assessor with experience in the particular challenges associated with the condition(s) involved, and a more comprehensive approach to collecting information to ensure all needs are effectively managed. 

complex care management

Do any home adaptations need to be made for complex care?

Home adaptationsare changes that must be made to a person’s house in order to make living there safer and more comfortable. Whether this means installing grab rails to help with mobility challenges, equipment to make life easier for those with dexterity issues, or reminders and instructions added around the home to help those with cognitive struggles, home adaptations can be made to help with a number of complex needs.  

Home adaptations can enable people to continue living independently with an enhanced quality of life. Examples of helpful home adaptations could be changes such as: 

  • Fitting a stairlift to make going up and down stairs safer and easier 
  • Installing grab rails or ramps in areas where levels change, both inside and outside the house 
  • Lowering kitchen countertops to make meal preparation and cooking easier
  • Installing community alarms to alert local operators or family members to any falls or other emergencies
  • Providing equipment and devices to make life easier for those with dexterity issues, such as adapted kitchen utensils or gripping aids 
  • Adding instructions around the house to help those with dementia conditions continue to live normally 
  • Moving furniture or removing excess clutter to make moving around more streamlined for those with reduced vision 
  • Creating designated spaces in the home for any visiting medical care, such as physical therapy, occupational therapy, or something else 
  • Installing equipment for home health monitoring, such as equipment for oxygen therapy, diabetes monitoring, and more 

These are only a few of the many home adaptations that can be made to help those with complex needs, and a Care Needs Assessment can provide more information about specific adaptations that could help in the case of you or your loved one.

You can read more about this in our guide to home adaptations for disabled older people.

How do I transfer my loved one from hospital to home?

Often those with complex needs will spend time in hospital to manage difficult symptoms of their condition. As an example, a person with breathing difficulties may need to be admitted to hospital if their breathing becomes particularly laboured. 

The transition from hospital to home (and vice versa) can be stressful for all involved. Studies on parents of children with complex needs report feeling exhausted and stressed during this process, and similar experiences are reported in adults with complex needs. 

According to NHS Improvement, hospital discharge should be included as part of a patient’s treatment plan, and medical teams should organise this as early as possible alongside an advocate for the patient. A complex carer could be the ideal person to do this, and should take a person-centred care approach to transferring a person with complex needs from hospital to home. Studies show the importance of this for older adults, as many who return to hospital have not been taking the recommended medications due to a lack of understanding at the time of discharge. Having a complex carer be part of this process could ensure better adherence to medical instructions, and therefore a reduced chance of readmission. 

For anyone with complex needs, the Care Plan should include a detailed record of what care is taking place so that this can be easily transferable between hospital and home settings. 

The logistics of transferring someone with complex needs to and from hospital can be tricky, so including this in the Care Plan is important. Studies have identified multiple risks in the process of transitioning a patient from hospital to home, including communication issues, organisational issues, medication provisions, and poor quality of handover instructions.

It is recommended that during a hospital stay, the complex carer should remain in touch with hospital staff, share relevant information from the Care Plan, and begin making arrangements as soon as possible with the hospital discharge coordinator for bringing the patient home. They could also collect contact numbers in case of further issues or readmission, and arrange follow-ups with relevant hospital staff. 

The Care Plan should be updated with any additional information gained from the hospital admission, new medications or treatments, and ongoing care needs. In addition, any new necessary medical equipment and supplies should be delivered to the home before the patient is discharged, if possible.

How can a carer support complex care management and care planning? 

Carers are integral to complex care management and care planning for those with complex needs, and will be required to work together with medical staff to create a holistic approach to care. This should encompass all of the person’s physical, psychological and social needs. 

Studies show that home care for older adults is often arranged too late after hospital admission, a rapid health decline, or when family caregivers are already hitting the stage of carer burnout. For this reason, being proactive when it comes to support from a carer is crucial to ensure a smooth transition for the person with complex needs. 

Carers can help by facilitating communication with healthcare professionals, coordinating appointments with other carers, ensuring adherence to medication schedules, and more. In addition, complex carers are typically still involved with daily activities like personal care, meal preparation, mobility support and more, depending on the specific needs of the person and what is included in their Care Plan. 

Carers are essential to the smooth-running care process as they will observe and report changes in the person’s health status, enabling early intervention which can be life-preserving in some cases. Carers also provide vital emotional support, companionship and advocacy, which can empower an individual with complex needs to navigate their healthcare journey with dignity and confidence. 

At Home Instead, our Care Professionals are specially trained to ensure they can effectively help the person they are caring for and address all of their needs. With the latest care training, workshops, safeguarding and more, we can ensure you are paired with the best Care Professional to suit your exact needs.

If you are currently looking to put home complex care in place for a loved one in order to manage care planning, our award-winning home care team can help by offering the bespoke, person-centred care you need. Reach out to the Home Instead team to discuss your needs and allow us to create a personalised package to support you.