Care Plans
From Patient Determinants
A clearly communicated care plan must be developed to ensure Care Goals and health outcomes are achieved. 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 may need to be developed
- Diagnosis - physical conditions, mental health conditions and ICD codes based on evidence
- Symptoms
- Functional Status
- 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 and effectively managing health
- Determinants - patient determinants that could impact health outcomes
- Shared Decision Making - patient and physician mutual understanding of Medical Interventions and Non-Medical Interventions based on understanding of diagnosis, symptoms, functional status, risk factors, prognosis, barriers and determinants
- Medical Interventions
- Non-Medical Interventions
- Patient/Caregiver 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)
- Realities Mapping
