Care Plans and Legos

1. Care Plans and Legos

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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 Team Members Prioritized Interventions

9. Putting the PoC Legos Together Level 1: Core Level 2: LongitudinalLevel 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 Team Members Prioritized Interventions

10. The “Core” PoC Establish Index of 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 Team Members Prioritized Interventions

11. The “Core” PoC Establish Goals of Care 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 Team Members Prioritized Interventions

12. “Core” Plan of Care “Core” Plan of Care Prioritize Goals of Care 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 Team Members Prioritized Interventions

13. “Core” Plan of Care Filter Health Concerns by Prioritized 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 Team Members Prioritized Interventions

14. “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 Team Members Prioritized Interventions

15. “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 Team Members Prioritized Interventions

16. “Longitudinal” Plan of Care Develop Prioritized Interventions 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 Team Members Prioritized Interventions

17. “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 Team Members Prioritized Interventions

18. “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 Team Members Prioritized Interventions

19. “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 Team Members Prioritized Interventions

20. “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 Team Members Prioritized Interventions

21. “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 Team Members Prioritized Interventions

22. 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 Team Members Prioritized Interventions

23. Repeat the Cycle Modify Health Concerns Modify Goals of Care 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 Team Members Prioritized Interventions

24. 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 Team Members Prioritized Interventions