Clinical Plans Can Fail Between Appointments

Fill in the implementation gap by providing short, approved support instructions.

A clinician may agree that something will work, but the patient comes back weeks later having never carried it out at home.

This barrier can be memory, transport, fatigue, communication, worker inconsistency or no one being authorised and trained to support the routine.

Why this matters for medical professionals

Clinically, medical professionals are faced with a limited amount of time for making decisions, and implementation happens at the level of homes, transport systems, support rosters and other daily routines. A small amount of functional and coordination information can show why an appropriate clinical plan is not working. The intent, of course, is not to pass clinical ownership, but to clarify the real-life process and feedback.

What better coordination looks like

To help with the implementation, medical professionals can determine the daily action needed, who will help the person carry it out, what information they need and how they will be told about the change.

Translate the action

Explain the practical routine, timings and desired outcome in language that the person and authorised supporters can use.

Identify the support requirement

Discuss what prompting, physical assistance, equipment or environmental adjustment is needed.

Create a feedback loop

Identify observations that are helpful, where to provide them, and when they need to be seen sooner.

Make the change last

A helpful change is meaningful and manageable. Decide who's going to take the first step, and agree who is going to keep a record of the decision and when the person will be asked if it helped. When it relies on multiple services, double check each party's readiness rather than relying on an agreement in a meeting. Keep the good, change the not so good and end the temporary solutions that are not achieving the desired results.

Questions for the next review

How would “translate the action” look from the person's point of view?

Which part is still assumed or requested?

What will the person and the team observe to determine that this approach is working or not?

Keep the boundary clear

Support workers should never be required to interpret clinical instructions, make a diagnosis, or use their training or delegation to perform tasks that are outside of their scope. Apply formal plans as necessary.

A practical example

A rehabilitation exercise plan was rarely completed, because the instructions sat in a clinic portal the worker could not access. The therapist was able to give a simple authorised routine and reporting prompt with the consent of the individual. Adherence improved.