• Creating Care Plans for Patients with Complex Needs

    Maggie Van Dyke Sep 08, 2014

    The current lack of interactivity among providers means that most have to rely on a patchwork approach to developing and sharing care plans for patients.

    In a Leadership article about improving care for older adults, experts point to the need for individualized care plans. The plans would help ensure that all the services a patient needs—including health care, support care, and transportation—are coordinated across care sites.

    The ideal care plan would reflect the patient’s goals and address socioeconomic as well as clinical issues. Information would be electronically shared and updated across all caregivers and care sites—including inpatient, skilled nursing, home care, and outpatient care—ensuring that everyone could access a comprehensive, up-to-date plan.

    But this ideal is not yet being realized except in cases where a patient receives all care from a single service provider. “People are really trying to figure out how to get a care plan that goes with the patient and is adapted and changed for the patient as they change levels of care,” says Kyle R. Allen, DO, vice president for clinical integration and medical director geriatric medicine, Lifelong Health Riverside Health System, Newport News, Va. “I don't think anybody has figured out how to do that very well yet.”

    One of the main challenges is the lack of interactivity between providers that are not in the same health system. “Getting outpatient providers to communicate a care plan to inpatient providers, and vice versa, is a real challenge,” says Susan Hazelett, BSN, RN, MS, manager, Seniors Institute Research, Summa Health System, Akron, Ohio.

    Two Patchwork Solutions

    Until a technology-enabled care plan can be realized, Allen and Hazelett believe in the benefit of a partial solution that helps ensure continuity of care. Both have been conducting research on how to improve care for the frail elderly since the early 1990s.

    An ambulatory care plan. As part of one of their studies, Allen and Hazelett developed a paper-based care plan that patients and their caregivers could share with all providers to communicate and coordinate outpatient and home-based care.

    Access the tool: Sample Ambulatory Care Plan for Frail, Older Adults

    The plan can also be shared with hospital staff when a patient is admitted, Hazelett says. “Presenting this care plan, along with any advance directives, when the patient is hospitalized could help determine appropriate goals of care and inform discharge planning.”

    A hospital admission plan. Another example of a partial solution is the hospital admission plan of care that Southeast Texas Medical Associates (SETMA) uses. The San Antonio-based patient-centered medical home developed the hospital admission plan of care template to help patients transition into the hospital setting and communicate the physician's plan of care to the patient's care team.

    "This tool is intended to help address major problems that can stem from a lack of coordination, such as unnecessary days in the hospital, low patient satisfaction, rehospitalizations, and inadequate staff communications," says James L. Holly, MD, SETMA's CEO.

    Access the tool: SETMA Hospital Admission Plan of Care Document

    The Comprehensive PACE Approach

    Held up by many as an exemplar program for frail elders who want to remain in their homes, the Program for All-Inclusive Care for the Elderly (PACE) has provided integrated and comprehensive care plans since its inception in the 1970s. The majority (89 percent) of the 100+ PACE organizations now have electronic health records that allow patient care plans to be shared and updated electronically across all employed or contracted PACE providers, according to Shawn Bloom, president and CEO, National PACE Association, Alexandria, Va.

    A Centers for Medicare & Medicaid Services’ manual outlines the care plan requirements for PACE programs:

    The IDT [interdisciplinary team] members consolidate the contents of the PACE care plan into a single comprehensive document that is filed in the care plan section of the participant’s medical record. The care plan clearly displays, at a minimum, the problem being addressed, interventions, measurable outcomes, time lines, and persons responsible for each intervention. It is continuously updated as the team monitors the participant’s health status.

    PACE programs receive fixed per-member-per-month (PMPM) fees from Medicare and Medicaid to provide all the services that patients need—from home-based support services to hospital care, as described in a related Leadership article. PACE programs directly employ their physicians, nurses, and other outpatient providers and contract with local hospitals and nursing homes to provide acute and skilled care when necessary.

    A Critical Tool

    Some experts believe that a comprehensive care plan will make a significant difference in providing patient-centered care, as well as reducing unnecessary costly treatments. “A care plan is probably the item that is missing the most in an individual’s health care,” says Joanne Lynn, MD, director, Altarum Institute’s Center for Elder Care and Advanced Illness.

    “Some doctors think it’s enough to list the patient’s medications and maybe a therapy or two. But that doesn’t provide a comprehensive look at the person’s situation and what resources they bring to the situation. For example, living on a farm with family members who are willing to help you is a very different circumstance than living all alone in a third floor walk-up. So we need to know those things and build a good care plan around each patient’s needs.”

    Quoted in this article:
    Shawn Bloom is president and CEO, National PACE Association, Alexandria, Va.

    Kyle R. Allen, DO, is vice president for clinical integration and medical director geriatric medicine, Lifelong Health Riverside Health, System, Newport News, Va.

    Susan Hazelett, BSN, RN, MS, is manager, Seniors Institute Research, Summa Health System, Akron, Ohio.

    James L. Holly, MD, is adjunct professor at University of Texas Health Science Center-San Antonio, and CEO, Southeast Texas Medical Associates, Beaumont, Texas.

    Joanne Lynn, MD, is director, Altarum Institute’s Center for Elder Care and Advanced Illness.

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