April 22, 2024: What is a Care Plan?

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 9

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A care plan is what the clinicians do all the time. We see patients and decide here’s how we’re going to manage this problem either with medication or behavior changes or testing that needs to be done for follow-up. We do a lot of this work already in our clinical notes. What we’re asking the clinicians and the clinical team to do is to write notes in order to share that information across the teams and across the specialties. It provides a consistent place where we look in order to know what the current plan of care is for that particular problem. That’s really the goal of what we’re trying to work on. Find a place in your electronic record where this communication can happen. We believe the best place for this to happen is in the problem list.

You keep an active problem list that’s up to date on every patient with active problems. Here’s the plan of care for each of those problems. It’s in a centralized location so you don’t have to dig through encounters or notes in order to figure out what’s the plan for their CHF. It’s right there in the problem list so everybody’s clear what the care plan is and then if somebody needs to modify it, whether it’s another specialty clinician that’s seeing the patient or maybe the care management nurse who’s on the phone with the patient, if something needs to be changed or updated it can be done in one place

We love the term “storyboard” where in an EMR it tells the story of a person and their needs and the commitment of the team to execute against that. We don’t know if that’s common in all EMRs but that’s the one that we’ve been using in Jamaica Hospital that works.

Many of the other EMRs have a similar kind of panel that shows what the overall care is for the patient, but it’s often very broken up. But the problem list in Epic, for instance, is in the Storyboard and you can hover your mouse over it and it pops up another window and it shows all the active problems. Brilliantly it also includes the content in the overview box of Epic in that snapshot view which actually has their care plan written in it if you’ve put it in there. That’s why we’re working with those teams to use that overview section of the Epic problem list in order to record the care plans.

The key to implementing the Advanced Primary Care model is to increase case management and clinical integration. The patient is connected to the primary care team and both are connected to the sub-specialty services when those are needed. It must all be woven together seamlessly.

Scott Conard, MD              Michael Tuggy, MD                  Susan Lindstrom                 Laurence Bauer, MSW, MEd

scott@scottconard.com   MTuggy@converginghealth.com   slindstrom@mypha.com   Laurence.bauer@gmail.com