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Care Plans
The care team and patient, family, and caregiver collaborate to develop and update an individual care plan at relevant visits for those patients identified as benefiting from care management.
POLICY
It is the policy of the Practice to manage all of the patient’s medical needs. The Practice uses evidence-based guidelines to plan and manage patient care; and when deviations occur, a rationale and explanation are documented in the record. To ensure that each patient receives appropriately individualized care, the Practice develops an individual care plan for each patient who is identified as benefiting from care management. The individual care management plans are created by the Provider in collaboration with the patient, family, and caregiver. These care plans describe treatment goals and they are reviewed and updated at relevant visits.
PROCEDURE
The Practice anticipates the needs of each patient scheduled. The Practice gathers medical history and other relevant information via secure electronic communication from patients before scheduled visits. Each day, employees conduct pre-visit preparations for the patients scheduled for the next day. These include a review of the patient’s medical record evaluating the presence of test results, imaging interpretations, operative reports, consultative summaries, and any other documentation needed for the patient’s visit. The provider reviews these materials before the patient’s encounter. If the information is unavailable, the source (e.g., imaging facility) is contacted immediately to communicate the results.
All patients benefit from pre-visit planning. Providers may also identify patients who would benefit from care management. In collaboration with the patient, family, and caregiver, the Practice develops an individual care plan for each of these patients that addresses whole-person care. The care plan specifies the services offered by, and responsibilities of, the medical home and, if appropriate, integrates with a care plan created for the patient by a non-primary care, specialty practice to avoid potential overlap or gap in services and care. The care plan incorporates patient preferences and functional/lifestyle goals. The care plan includes treatment goals that are reviewed and updated at each relevant visit. Relevant visits may include important or chronic conditions, including well-child visits, visits that result in a change in treatment plan or goals, additional instructions or information for the patient, family and caregiver, and visits associated with transitions of care. At each relevant visit, as determined by the patient’s provider, the provider uses indicators from evidence-based guidelines to determine the patient’s progress with the care plan and treatment goals. The provider documents no change, if applicable. The provider also documents any deviations from established guidelines and includes the rationale.
The Practice provides the patient, family, and caregiver with a written plan of care tailored for the patient’s use at home and to the health literacy and language preferences of the patient, family, and caregiver.
The Practice assesses and addresses potential barriers when the patient has not met treatment goals. The assessment may include discussions with the patient, family, and caregiver to determine the reasons for limited progress toward treatment goals. The provider helps the patient, family, and caregiver address barriers (for example, insurance issues or transportation problems). The provider changes the treatment plan or adds treatment, if appropriate.
In summary, a care plan considers and/or specifies including, but not limited to, the elements listed below:
- Patient preferences and functional/lifestyle goals
- Treatment goals
- Assessment of potential barriers to meeting goals
- Strategies for addressing potential barriers to meeting goals
- Care team members, including the primary care provider of record and team members beyond the referring or transitioning provider and the receiving provider
- Current problems (may include historical problems, at the provider’s discretion)
- Current medications
- Allergies and medication allergies
- Self-care plan
The Practice assesses and identifies patients, families, and caregivers who might benefit from additional care management support. The provider refers the patient to internal or external resources, as is deemed clinically appropriate. The resources may include disease management or case management programs.
QUALITY CONTROL
The Practice monitors the policy and procedure in the following manner:
- Annual audit to ensure that the patient’s medical record is available to staff for pre-visit review 100 percent of the time.
- Annual audit to ensure that the patient’s medical record is previewed prior to all scheduled appointments.
