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