care plans and legos. approach start by asking the “receivers” of a plan of care “what do you...
TRANSCRIPT
Care Plans and
Legos
Approach
• Start by asking the “receivers” of a plan of care “What do you need and want in the plan?”
• Define the “output” of a plan of care– What will it be used for?– What are the key components of the output?– What does it look like?
• Define the “inputs” necessary to create the “outputs”
• Leave the “process” of converting inputs to outputs for another day
Nested Plans of Care - Three Flavors
• Level 1: The “Core Plan of Care”– High level– Defined by the Patient and Advisor
• Level 2: The “Longitudinal Plan of Care”– Plan to inform care across all sites, all episodes– Requires a “Steward” to maintain and deploy
• Level 3: The “Local Plan of Care”– Site and/or issue specific plans (HHA, Burn Unit, etc)– Local implementation (site, practice, clinician)– Defined by Care Team and Clinician
Level 1: “The Core Plan”
• The “Big Picture” or “Master” Plan of Care (PoC)• Plan Owner: Patient, Surrogate/Advisor • Inputs:
– Patient defined goals (Longevity, Function, Comfort)
– Relative importance of goals– Prioritized list of Health Concerns– Limitations on interventions
• Outputs:– Prioritized list of health concerns matched to goals – List of any explicit limitations on interventions
Level 2: The “Longitudinal” PoC
• The “Multi-site” PoC• Plan Owner: PoC “Manager” (Steward, PCP, CM,
Navigator) whose role is to collaborate with the Patient to translate the Core Plan into a blueprint for action
• Inputs:– Prioritized list of Health Concerns matched to Goals– Prioritized Interventions matched to Goals– Team Members Accountable for Implementation matched to
Health Concern(s)
• Output: – List of Accountable Providers matched to each Health Concern– Measurable outcomes for each Intervention
Level 3: The “Local” PoC
• The “Condition” or “Site Specific” PoC• Plan Owners: Multiple. The local Team, Site and/or
Accountable Providers• Inputs:
– List of Prioritized Interventions– List of Accountable Providers matched to each intervention– Measurable outcomes associated with each Intervention
• Outputs: – Assessment of success of each intervention– Recommendations for any changes to Core or Longitudinal
PoCs based on response
Legos Needed for These Plans
• Health Concerns• Patient Goals of Care• Prioritized Goals of Care• Cross-walk of Goals and Health Concerns• Prioritized Health Concerns• Prioritized Interventions• Team Members• Accountable Team Members• Anticipated/Desired Outcomes by Intervention• Changes in Goals, Concerns and Interventions
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
PoC Legos
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
Putting the PoC Legos Together Level 1: Core Level 2: Longitudinal Level 3: Local
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
The “Core” PoC
Establish Index of Health Concerns
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
The “Core” PoC
Establish Goals of Care
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Core” Plan of Care
Prioritize Goals of Care
“Core” Plan of Care
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Core” Plan of Care
Filter Health Concerns by Prioritized Goals
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Core” Plan of Care
Produce Crosswalk
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Core” Plan of Care
Produce List of Prioritized Health Concerns
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Longitudinal” Plan of Care
Develop Prioritized Interventions
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Longitudinal” Plan of Care
Create list of Accountable Team Members
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Longitudinal” Plan of Care
Assign outcomes to Responsible Team Member
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Longitudinal” Plan of Care
Establish measurable outcomes
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Local Entity” Plan of Care
Measure Progress towards desired outcomes
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
“Local Entity” Plan of Care
Identify changes to Goals, Concerns
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
Repeat the Cycle
Modify Health Concerns Modify Goals
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare
Repeat the Cycle
Modify Health Concerns Modify Goals of Care
Index of Health
Concerns
Changes: GoalsConcerns andInterventions
PrioritizedGoals of Care
Outcomes byIntervention
AccountableTeam
Members
CrosswalkOf ConcernsAnd Goals
PrioritizedHealth
Concerns
PrioritizedInterventions
TeamMembers
Goals ofCare