Care Plan Development

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)