Care Plan Development
From Patient Determinants
A clearly communicated care plan must be developed to ensure a successful health outcome. The following types of care plans
- Preventive & Wellness - This care plan is typically addressed with the Annual Wellness Visit
- Episode - This care plan is developed in the physician office, emergency room or hospital to ensure the treatment address the acute condition
- Chronic Care - This care plan address the long term management of chronic conditions
The following are components of the care plan that must be developed
- Diagnosis - patient and physician mutually understanding of the diagnosis
- Prognosis - patient and physician mutually understanding of the diagnosis means to their health, risk factors and the potential progression
- Shared Decision Making - patient and physician alignment of treatment options
- 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)
