Patients with complex needs often see multiple providers for different health conditions, including providers in emergency departments, multiple health systems, and in mental health services. Coordinated care plans can help keep all providers informed about the patient’s needs and preferences, helping to coordinate care and decrease waste. While the concept is simple, the implementation of care plans can be challenging. Useful care plans must be concise, goal-oriented, and up-to-date, and there may be no pre-existing way to share care plans within and across health systems.
The goal of this play is to help engage patients and families in person-centered co-design.
- Create a template for a coordinated care plan, with input from patients, families, primary care providers, and emergency departments.
- Identify the health care provider(s) who will complete the Coordinated Care Plan with the patient and be accountable for keeping it up-to-date.
- Determine which patients will have a care plan. Consider whether care plans may be required for patients with certain conditions, and which conditions may make care plans more useful, such as chronic disease and patients who are taking opioids for pain.
- Develop systems to share the care plan internally (among providers within your health system) and with key external stakeholders (such as mental health services and other health systems that may see the patient).
- It’s important to design a care plan that contains key information that is easily accessible and accurate to make the plan useful to key stakeholders, especially emergency department physicians who want a concise summary of the patient’s issues in an emergency situation.
- If a care plans become out-of-date, providers may stop referencing them altogether. When designing your care plan, avoid adding details such as medications that may become out-of-date quickly.
- Electronic health records may not have a place for a care plan, and these systems may not be available to all the providers who see a patient. Health information exchanges can help with this problem, and one solution is to have patients carry their care plans with them. Determining how the care plan will be shared is key to its success.
- Patients must play an important role in the creation and use of their care plans. Plans should be co-created by patients and providers, and patients themselves may share their care plans when they visit different providers.
- The care plan is a living document; it should be updated with changes in the patient’s life and goals. It's helpful to identify a person who is responsible for updating it within a defined process.
- Consider using different care plans for patients with different goals. For example, a Physician Orders for Life Sustaining Treatment (POLST) Paradigm is one type of care plan that helps guide treatment for patients who are near the end of life.
FOR MORE INFORMATION
- Learn how to co-create shared care plans from the Agency for Healthcare Research and Quality. You may also be interested in shared care plans developed in Whatcom County, Washington, as part of the Pursuing Perfection initiative of the Institute for Healthcare Improvement.
- Download example care plans from Health Quality Ontario (including a companion user guide), from the American Academy of Family Physicians, and from the American Society of Clinical Oncologists (which offers cancer-specific care plans).
- Learn about Washington State’s Emergency Department Information Exchange, which allows health systems to share care plans and receive notifications about patients’ emergency department visits.
- Learn more about the POLST Paradigm and components of the form.
- For more information on the Better Care Playbook: