Quality standard
Quality statement 2: Personalised care plan
Quality statement 2: Personalised care plan
Quality statement
Adults with bipolar disorder have their early warning symptoms and triggers of relapse, preferred response during relapse and personal recovery goals specified in their care plan.
Rationale
Bipolar disorder is a long‑term condition that involves periods of wellbeing that may end abruptly because of relapse into mania, hypomania or bipolar depression. It is important for adults with bipolar disorder to have a personalised care plan in which they specify the care they want to receive, particularly in a crisis. It is also important that their care plan is focused on maintaining wellbeing, preventing relapse and achieving recovery goals. Specifying early warning symptoms and triggers in the care plan allows health and social care practitioners and carers to be alert to these and to intervene early to prevent or prepare for a crisis.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of practice arrangements and written clinical protocols to ensure that care plans specify early warning symptoms and triggers of mania and depression relapse, preferred response during relapse and personal recovery goals.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, audit of clinical protocols or care plan templates.
Process
a) Proportion of adults with bipolar disorder who have a care plan that specifies early warning symptoms of mania and depression relapse.
Numerator – the number in the denominator who have a care plan that specifies early warning symptoms of mania and depression relapse.
Denominator – the number of adults with bipolar disorder who have a care plan.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from care plans.
b) Proportion of adults with bipolar disorder who have a care plan that specifies triggers of mania and depression relapse.
Numerator – the number in the denominator who have a care plan that specifies triggers of mania and depression relapse.
Denominator – the number of adults with bipolar disorder who have a care plan.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from care plans.
c) Proportion of adults with bipolar disorder who have a care plan that specifies preferred response during mania and depression relapse.
Numerator – the number in the denominator who have a care plan that specifies preferred response during mania and depression relapse.
Denominator – the number of adults with bipolar disorder who have a care plan.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from care plans.
d) Proportion of adults with bipolar disorder who have a care plan that specifies personal recovery goals.
Numerator – the number in the denominator who have a care plan that specifies personal recovery goals.
Denominator – the number of adults with bipolar disorder who have a care plan.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from care plans.
Outcome
a) Adults with bipolar disorder who feel enabled to self‑manage their condition.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient questionnaires.
b) Health‑related quality of life for adults with a long‑term mental health condition.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient questionnaires.
c) Frequency of relapse rates among adults with bipolar disorder.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
What the quality statement means for different audiences
Service providers (such as secondary care services, GP practices and community mental health services) ensure that systems are in place for adults with bipolar disorder to specify in their care plan early warning symptoms and triggers of mania and depression relapse, preferred response during relapse and personal recovery goals.
Healthcare professionals collaborate with adults with bipolar disorder to develop a care plan that specifies early warning symptoms and triggers of mania and depression relapse, preferred response during relapse and personal recovery goals.
Commissioners commission services that ensure that adults with bipolar disorder have a care plan that specifies early warning symptoms and triggers of mania and depression relapse, preferred response during relapse and personal recovery goals.
Adults with bipolar disorder have a care plan that specifies what to look out for that might mean they are becoming unwell again or things that might act as a 'trigger' to becoming unwell, what the person would prefer to happen if they become unwell again and their personal recovery goals.
Source guidance
Bipolar disorder: assessment and management. NICE guideline CG185 (2014, updated 2023), recommendations 1.3.2 and 1.9.4
Equality and diversity considerations
Some adults with bipolar disorder may find it difficult to express their needs and aspirations. They may also find it difficult to understand bipolar disorder and what options they have for living well with the condition. Healthcare professionals who develop care plans with adults who have bipolar disorder should ensure that they support these adults to understand the condition and the options available, using carers, interpreters or advocates if needed.