Care Plan Development
From Patient Determinants
A clearly communicated care plan must be developed to ensure a successful health outcome. The following are the typical types of care plans:
- Preventive & Wellness - Care plan typically addressed with the Annual Wellness Visit
- Episode - Care plan developed in the physician office, emergency room or hospital to ensure effective treatment of acute conditions
- Chronic Care - care plan to address long term management of chronic conditions
- Complex - care plans for High Need High Cost patients
- Advanced - care plan based on Advanced Care Planning for end of life and Palliative Care
The following are components of the care plan that must be developed
- Diagnosis - health and mental health conditions (ICD) based on evidence
- Functional limitations
- Risk Factors - patient risks for health conditions with recommended screening and treatments
- Prognosis - understanding of the diagnosis and risk factors to current health conditions and potential progression
- Barriers - patient barriers for treatment options
- Determinants - patient determinants that could impact health outcomes
- Shared Decision Making - patient and physician mutual understanding of healthcare treatment options, E Interventions and PC Interventions based on understanding of diagnosis, risk factors, prognosis, barriers and determinants
- Healthcare Interventions
- E Interventions
- PC Interventions
- Care Goals - clearly articulated care goals of the care plan
- Communication - within the Care Team members
- Alignment - ensure the interventions, activities and actions are aligned with Care Goals
- Integration - ensure the interventions are integrated
- Care Team - identification (including Social Workers, Pharmacists, Social Services, etc.), planned actions, roles and communication
- Qualified Option development - explore the many facets of healthcare decision making (i.e., Complex Cancer Treatment Options, End-of-Life)
