Individual care plan and coordinator
Anyone in need of long-term and coordinated health and care services is entitled to have an individual care plan prepared for them. The plan should only be prepared if the person concerned wants one.
The patient's and user's goals must form the starting point for the individual care plan. It is therefore important that the patient and user actively participates in the preparation of the plan. Next of kin must also be given the opportunity to be involved insofar as the patient and user permits this.
The plan should be continually updated and be a dynamic tool for coordinating and focussing the services that are provided.
How to get an individual care plan
The initiative to create an individual care plan can come from the user themselves or next of kin, but primary responsibility for preparing individual care plans rests with the service system.
The coordinating unit for habilitation and rehabilitation has primary responsibility for individual care plans and for appointing coordinators. Enquiries concerning individual care plans should be addressed there. Healthcare professionals are also obliged to notify this unit of individual care plan needs.
The municipality has primary responsibility for individual care plans
The municipality has primarily responsibility for preparing individual care plans when the patient receives services from both the municipality and the specialist health service. The specialist health service must be involved in the planning process. They must also notify the municipality of any need to prepare individual care plans.
Only one plan should be drawn up even if the patient or user receives services from several sectors.
One of the service providers must be appointed as a coordinator, who will be responsible for arranging essential follow-up of the individual patient or user. The coordinator must also coordinate the provision of services and progress in the implementation of individual care plans.
The wishes of the patient and user should be given emphasis when a coordinator is chosen.
A coordinator must be offered even if the patient and user do not wish to have an individual care plan.