Difference between revisions of "Care Plan Development"
From Patient Determinants
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A clearly communicated care plan must be developed to ensure a successful health outcome. The following are the typical types of care plans: | 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 | + | * ''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 | + | * ''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 | + | * ''Chronic Care'' - care plan to address long term management of chronic conditions |
| − | * Complex - care plans for High Need High Cost patients | + | * ''Complex'' - care plans for High Need High Cost patients |
| − | * Advanced - care plan based on Advanced Care Planning | + | * ''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 | The following are components of the care plan that must be developed | ||
| − | * Diagnosis - | + | * Diagnosis - health and mental health conditions (ICD) based on evidence |
| + | * Functional limitations | ||
* Risk Factors - patient risks for health conditions with recommended screening and treatments | * 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 | * Prognosis - understanding of the diagnosis and risk factors to current health conditions and potential progression | ||
Latest revision as of 09:02, 23 November 2016
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)
