Care Plans and Legos

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Care Plans and Legos
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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

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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

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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
  

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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

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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

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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

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PoC Legos
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Putting the PoC Legos Together Level 1 Core
Level 2 Longitudinal
Level 3 Local
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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The Core PoC
Index of Health Concerns
Goals of Care
Establish Index of Health Concerns
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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The Core PoC
Index of Health Concerns
Goals of Care
Establish Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Core Plan of Care
Core Plan of Care
Index of Health Concerns
Goals of Care
Prioritize Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Core Plan of Care
Index of Health Concerns
Goals of Care
Filter Health Concerns by Prioritized Goals
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Core Plan of Care
Index of Health Concerns
Goals of Care
Produce Crosswalk
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Core Plan of Care
Produce List of Prioritized Health Concerns
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Longitudinal Plan of Care
Index of Health Concerns
Goals of Care
Develop Prioritized Interventions
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Longitudinal Plan of Care
Create list of Accountable Team Members
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Longitudinal Plan of Care
Assign outcomes to Responsible Team Member
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Longitudinal Plan of Care
Establish measurable outcomes
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Local Entity Plan of Care
Measure Progress towards desired outcomes
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Local Entity Plan of Care
Identify changes to Goals, Concerns
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Repeat the Cycle
Modify Health Concerns Modify Goals
Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Repeat the Cycle
Index of Health Concerns
Goals of Care
Modify Health Concerns Modify Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members
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Index of Health Concerns
Goals of Care
Changes Goals Concerns and Interventions
Prioritized Goals of Care
Outcomes by Intervention
Crosswalk Of Concerns And Goals
Accountable Team Members
Prioritized Health Concerns
Prioritized Interventions
Team Members