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Longitudinal Care Planning

Longitudinal Care Planning. A Vision of the Longitudinal Coordination of Care Workgroup June 10, 2012. LCC Workgroup Leads/Co-authors. Larry Garber, MD LTPAC Care Transitions Terry O’Malley, MD LTPAC Care Transitions Bill Russell, MD Longitudinal Care Plan

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Longitudinal Care Planning

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  1. Longitudinal Care Planning A Vision of the Longitudinal Coordination of Care Workgroup June 10, 2012

  2. LCC Workgroup Leads/Co-authors • Larry Garber, MD LTPAC Care Transitions • Terry O’Malley, MD LTPAC Care Transitions • Bill Russell, MD Longitudinal Care Plan • Joanne Lynn, MD Longitudinal Care Plan • Laura Heermann Langford,PhD,RNLongitudinal Care Plan • Russ Leftwich, MD Longitudinal Care Plan • Susan E. Campbell, PhD, RN Longitudinal Care Plan • Jennie Harvell Pt. Assessment Summary • Sue Mitchell, RHIA Pt. Assessment Summary

  3. Patient Status • Functional • Cognitive • Physical • Environmental Assessments Patients are evaluated with assessments (history, symptoms, physical exam, testing, etc…) to determine their status

  4. Health Conditions/ Concerns Active Problems Disease Progression • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Treatment Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Patient Status helps define the patient’s current conditions, concerns, and risks for conditions Risks/concerns come from many sources

  5. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Active Problems Disease Progression Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Treatment Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Goals for treatment of health conditions and prevention of concerns are created collaboratively with patient taking into account their statusesand Care Plan Decision Modifiers

  6. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Active Problems Disease Progression Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Treatment Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Decision making is enhanced with evidence based medicine, clinical practice guidelines, and other medical knowledge

  7. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Treatment Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Interventions and actions to achieve goals are identified collaboratively with patient taking into account their values, situation, statuses, risks & benefits, etc…

  8. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks The Care Plan is comprised of Modifiers, Conditions/Concerns, their Goals, Interventions/Actions/Instructions, Assessments and the Care Team members that actualize it

  9. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support Outcomes • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Outcomes Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Interventions and actions achieve outcomes that make progress towards goals, cause interventions to be modified, and change health conditions

  10. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support Outcomes • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Outcomes Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks The Care Plan (Concerns, Goals, Interventions , and Care Team), along with Risk Factors and Decision Modifiers, iteratively evolve over time

  11. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) 0…∞ 0…∞ 0…∞ 0…∞ A many-to-many-to-many relationship exists between Health Conditions/Concerns, Goals and Interventions/Actions

  12. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances Example: • Interventions/Actions • Metformin • Atorvastatin • Walking • Testing blood sugars • Call MD if FSBS>300 • Testing cholesterol • Testing liver enzymes • Testing muscle enzymes • Goals • A1C < 7 • LDL < 100 • Exercise 3x per week • Normal liver and muscle tests Health Conditions/ Concerns Care Plan Diabetes Mellitus Hyperlipidemia Disease Progression • Risks/Concerns: • Atherosclerosis • Hypoglycemia • Diarrhea • Myositis • Hepatitis 0…∞ 0…∞ 0…∞ 0…∞ Side effects

  13. Care Team Members each have their own responsibilities • Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental

  14. Patient Assessments and testing have many sources • Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental

  15. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental Registries and Clinical Decision Support used by the Patient-Centered Medical Home identify when patient assessments, testing and/or interventions are overdue, or other deviations from the Care Plan exist Registries and Clinical Decision Support in Patient-Centered Medical Home

  16. Care Plan transporting, synchronizing and viewing • Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) • Patient Status • Functional • Cognitive • Physical • Environmental The Care Plan is filtered, translated and transported to meet the needs of each participant/setting in the patient’s care

  17. How to represent many-to-many-to-many-to-many??? • Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) 0…∞ 0…∞ • Patient Status • Functional • Cognitive • Physical • Environmental 0…∞ 0…∞

  18. The MAP Master All-care Plan • Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) 0…∞ 0…∞ • Patient Status • Functional • Cognitive • Physical • Environmental 0…∞ 0…∞ • Master All-care Plan • Item #1 • Item #2 • Relationship (e.g. Goal-for-Problem, Intervention-for-Problem, Goal-for-Intervention, Performing Team Member-for-Intervention, Performing Team Member-for-Assessment, Team Member Responsible-for-Problem, Team Member Following-Problem, Problem-Problem Causality, etc…)

  19. The MAP Master All-care Plan enables many views • Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Family • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress • Patient • Coordinators • Nursing • Physicians • Non-physician Providers Health Conditions/ Concerns Care Plan Active Problems • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) What problems are treated by this intervention and what are the goals of treatment? 0…∞ 0…∞ Which problems am I responsible for? • Patient Status • Functional • Cognitive • Physical • Environmental Who on my Care Team is taking care of my wound? 0…∞ 0…∞ What interventions are in place for this health concern? • Master All-care Plan • Item #1 • Item #2 • Relationship (e.g. Goal-for-Problem, Intervention-for-Problem, Goal-for-Intervention, Performing Team Member-for-Intervention, Performing Team Member-for-Assessment, Team Member Responsible-for-Problem, Team Member Following-Problem, Problem-Problem Causality, etc…)

  20. Care Plan Decision Modifiers • Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) • Patient situation (access to care, support, resources, setting, transportation, etc…) • Patient allergies/intolerances • Interventions/Actions • (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) • Start/stop date, interval • Authorizing/responsible parties/roles/contact info • Setting of care • Instructions/parameters • Supplies/Vendors • Planned assessments • Expected outcomes • Related Conditions • Status of intervention • Goals • Desired outcomes and milestones • Readiness • Prognosis • Related Conditions • Related Interventions • Progress Health Conditions/ Concerns Care Plan Active Problems Disease Progression Orders, etc.. Prioritize • Risks/Concerns: • Wellness • Barriers • Injury (e.g. falls) • Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Decision Support Decision Support Outcomes • Patient Status • Functional • Cognitive • Physical • Environmental Assessments Disabilities/ Concerns Barriers Outcomes Side effects • Risk Factors • Age, gender • Significant Past Medical/Surgical Hx • Family Hx, Race/Ethnicity, Genetics • Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks Questions?

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