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Care Plans are Key in Patient-Centered Care, Research Shows

"...care plans are a key mechanism by which a person’s individual care and treatment can be developed, documented, modified and shared with everyone involved.”

By Sara Heath

Care plans have the power to assist providers in providing patient-centered care and accessing a complete picture of a patient’s health, according to a report by Chilmark Research.


Care plans are approaches to healthcare delivery that are patient-centered and integrate several providers. According to the report, these plans take into account various patient needs and provide patient information for physician access on EHRs.

“It outlines the patient’s short- and long-term needs, recovery goals, and coordination requirements, and it identifies who is responsible for each part of the plan,” the report states. “A number of people might create and maintain the care plan: The patient or family member, the healthcare team or, if necessary, community or social services.”

Furthermore, care plans should help facilitate provider communication, fostering a team-based approach to healthcare.

“Because many patients receive care from a number of loosely affiliated or unaffiliated care providers, coordinated care plans facilitate communication between the parties involved in a patient’s care,” the researchers write. “They help physicians and patients manage numerous medical therapies prescribed by various health professionals within the patient’s circle of care. Thus, care plans are a key mechanism by which a person’s individual care and treatment can be developed, documented, modified and shared with everyone involved.”

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Why are care plans growing in popularity?

The authors of the report observe that care plans are a growing trend in healthcare delivery, specifically due to the prevalence of federal incentive programs that foster coordinated care. These programs primarily use financial incentives to get healthcare organizations to perform more patient-centered, plan-oriented care.

For example, the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs promote the use of care plans through optional Stage 2 provisions and several Stage 3 requirements.

The researchers also referenced chronic care management coding, which reimburses chronic care providers monthly by meeting certain care plan criteria. Other federal incentive programs that promote care plans include accountable care organizations, bundled payments, and programs aimed at reducing readmissions.

How do providers approach care plan development?

Although the financial rewards and other patient-centered benefits of care plans are fairly ubiquitous across all points of care, approaches to care planning can vary. According to the researchers, there are several kinds of care plans healthcare organizations can utilize.

For example, clinical content vendors provide care plans for providers to adopt. The researchers explain that these vendor care plans provide a solid base for care planning, but aren’t necessarily advanced.

Physician specialty societies such as the American Society of Clinical Oncology or the American Academy of Family Physicians have past experiences in developing care plans that can be instructional for other providers looking to implement their own. By following by example and learning from other providers’ past mistakes, healthcare organizations can develop a personalized care plan approach.

No matter the care plan approach, Chilmark researchers have identified certain elements that should be a part of every care plan:

  • Basic patient demographics including name, age and sex

  • All current members of the patient’s care team including their spouse or family caregiver(s), PCP (if they have one) and the individual in charge of coordinating the care team activities for the patient

  • All treatment programs the patient is currently enrolled in

  • Active problems that need to be addressed

  • Goals including self-management goals

  • All interventions and the status of those interventions including their current completion status and their start and end dates

  • Risk factors or barriers

  • Active medication list

How do care plans work in different facilities?

Just as approaches for care planning can vary, execution of the care plan can depend on the type of practice. Chilmark categorized these different executions into three categories: physician practices, post-acute care practices, behavioral healthcare practices.

Physician practices are ideal settings for utilizing care plans due to the popular use of EHRs. Many common practices in physician practices include secure direct messaging, chart notes, and task assignments. The researchers also described a “huddle sheet” that several practices use to coordinate care across all providers.

“Some practices use their EHRs to help create a “huddle sheet,” which lists patients scheduled for the day and notes pertinent issues for each patient that might not already be included in the EHR,” the researchers write.

Post-acute care facilities tend to see more issues in developing care plans because of their limited funds and small size. However, the high volume of patients in post-acute care make care plans a necessity.

“Vendors are starting to develop, or acquire, solutions geared toward post-acute care. The result is that health IT for post-acute care facilities is expanding beyond bare-bones documentation and putting more emphasis on integration with other systems,” the researchers explained. “Vendors are also coming up with ways to accomplish broader goals of post-acute care.”

Care plans and care coordination are vital in behavioral healthcare settings because behavioral health professionals are often not practicing in the same facility as physical health practitioners. However, behavioral health specialists play an important role in the physical well-being of a patient, thus highlighting the importance of coordinated care across both behavioral and physical health professionals.

“New healthcare delivery models, such as accountable care organizations and health homes, as well as changes to healthcare financing, may enable more providers to incorporate practices that increase the integration of physical and mental health services, particularly the integration of physical health into behavioral health settings to help address the needs of individuals with [serious mental illness],” the researchers stated.

The researchers expect to see care plan development grow within coming years, especially due to the high usage of EHRs and the prevalence of patient-centered incentive programs. However, as care plans continue to emerge, the researchers emphasize that they are a developing concept and that they are still evolving.

“Over the next year or two, expect to see robust adoption of care management vendor solutions that utilize elements of a care plan as a key part of their workflow for a care team,” the researchers explained. “Adoption of the coordinated care plan across multiple care settings will still be very much a “work in progress” though; even basic features such as sending, receiving, and compiling care plan data elements will remain limited.”



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