ToC+-+Care+Planning+SWG

include component="page" wikiName="siframework" page="TOC Header"

Purpose and Goals
To develop more detailed User Stories for Care Planning to include data elements that are to be included as part of Care Planning documentation. Care Planning involves both the patient and healthcare team and is used to develop a plan of action that leads to improved patient well-being.

Meeting Details
Inivte to be sent for meetings

Meeting Summaries

 * **Meeting Date** || **Meeting Agenda** || **Meeting Summary** || **Date Posted** ||
 * 03/11/11 ||  || [|Meeting Summary] || 03/11/11 ||
 * 03/18/11 ||  || [|Meeting Summary] || 03/19/11 ||
 * 04/12/11 || [|Meeting Agenda] || [|Meeting Summary] || 04/13/11 ||
 * 04/14/11 || [|Meeting Agenda] || [|Meeting Summary] || 04/16/11 ||
 * 04/28/11 || [|Meeting Agenda] || [|Meeting Summary] || 04/29/11 ||
 * 05/05/11 || [|Meeting Agenda] || [|Meeting Summary] || 05/05/11 ||
 * 05/12/11 || [|Meeting Agenda] || [|Meeting Summary] || 05/12/11 ||
 * 05/19/11 || [|Meeting Agenda] || [|Meeting Summary] || 05/20/11 ||
 * 05/26/11 || ﻿[|Meeting Agenda] || [|Meeting Summary] || 05/27/11 ||
 * 06/02/11 || [|Meeting Agenda] || [|Meeting Summary] || 06/03/11 ||
 * 06/02/09 || [|Meeting Agenda] || [|Meeting Summary] || 06/10/11 ||
 * 06/14/11 || N/A || Meeting Summary - F2F || 06/17/11 ||
 * 06/23/11 || N/A || [|Meeting Summary] || 06/24/11 ||
 * 06/30/11 || Meeting Agenda || Meeting Summary || 06/30/11 ||
 * 07/20/11 || [|Meeting Agenda] || [|Meeting Summary] || 07/20/11 ||
 * 08/16/11 || [|Meeting Agenda] || [|Meeting Summary] || 08/16/11 ||
 * 08/24/11 || [|Meeting Agenda] || [|Meeting Summary] || 08/25/11 ||
 * 09/01/11 || [|Meeting Agenda] || [|Meeting Summary] || 09/02/11 ||
 * 09/13/11 || Consenus Discussion || Comments on Wiki || 09/13/11 ||

Outstanding Action Items from Sub-Workgroup Meetings

 * **Action Item** || **Status/Next Steps** || **Lead** || **Contributer** || **Date Due** ||
 * Consensus on Care Planning Document || In Progress || Dr. Miller/Dr. Leftwich || All || 09/19/11 ||
 * Submit document to ONC || In Progress || Dr. Leftwich || All || 09/20/11 ||

Participants
Susan E. Campbell || luann301@aol.com bostoncampbell@mindspring.com || Participant Participant ||
 * Name || Contact Information || Role ||
 * Amy Berk || amy.d.berk@accenture.com || Support Lead ||
 * Ed Larsen || e.larsen@ix.netcom.com || Support Lead ||
 * Greg Smith || greg@futurekansas.com || Lead ||
 * Dalana Ostlie || netmart@bigplanet.com || Participant ||
 * Kimberly Tooles || tooles.kimberly@yahoo.com || Participant ||
 * Laura Heermann || laura.heermann@imail.org || Particpant ||
 * Jim Hansen || Jim.Hansen@DossiaConsortium.org || Participant ||
 * Cyndalynn Tilley || cyndalynn.tilley@imail.org || Participant ||
 * Teresa Mota, BSN, RN || tmota@healthcentricadvisors.org || Participant ||
 * Rosemary Kennedy || Rosemary.kennedy@jefferson.edu || Participant ||
 * Annette Watson || awatson@taconicipa.com || Participant ||
 * Luann Whittenburg

**Add attachments related to the Care Planning Sub-Workgroup below!**

 * **Name** || **Creator** || **Creation Date** || **Comment** ||
 * [|HIT Enabled Care Coordination 2 8-ONC.docx] || CARE PLANNING WG || 09/19/11 || Final-Submitted to ONC ||
 * [|HIT Enabled Care Coordination 2 5.docx] || Laura et al || 09/06/11 || Final document up for Consensus ||
 * [|HIT Enabled Care Coordination in a Reformed Health Care System LKH and Laura et al (2) _ pt proof_first draft.docx] || Leslie Kelly Hall || 08/29/11 ||  ||
 * [|HIT Enabled Care Coordination in a Reformed Health Care System v2.docx] || Laura Heermann || 08/28/11 || This is the document to be reviewed and discussed!!!!! ||
 * [|Nursing Documentation appl to Content Modules.xlsx] || Laura Heermann || 08/02/11 ||  ||
 * [|Roadmap Dimensions 06302011-SEC - LKHL.xlsx] || Amy Berk || 07/05/11 ||  ||
 * [|CIM data elements - additional 6-10-2011 SE Campbell_LKHL.xls] || Amy Berk || 06/29/11 ||  ||
 * [|Roadmap Dimensions 06192011-8amET-SEC.xlsx] || Amy Berk || 06/29/11 ||  ||
 * [|Roadmap Dimensions 06192011-8amET.xlsx] || Greg Smith/Workgroup || 06/19/11 || Please review prior to Thursday's call ||
 * [|Data Element Category_UC Care Planning WG_0616.docx] || Dr. Leftwich/Miller || 06/16/11 || Please review and place comments on the Discussion Page ||
 * [|Roadmap Dimensions 06112011-8amET.xlsx] || Amy Berk || 6/14/11 ||  ||
 * [|Care Plan Overview 05272011 8pmET.docx] || Amy Berk || 06/13/11 ||  ||
 * [|Roadmap Dimensions 05272011-8pmET.xlsx] || Amy Berk || 06/13/11 ||  ||
 * [|MDS3 0_ALL_Item _Listing_v1 00 3.pdf] || Amy Berk || 06/09/11 ||  ||
 * [|Coded_Potential_Elements_Social_Hx_AnticipatoryGuidance.docx] || Luann Whittenburg || 06/09/11 ||  ||
 * [|Care coordination document_revised060211.docx] || Eva Powell || 06/03/11 ||  ||
 * [|Criteria to Advance Further in Stage 2_052711.docx] || Eva Powell || 06/03/11 ||  ||
 * [|FinalCareCoordination_nonmember1.pdf] || NQF || 06/03/11 ||  ||
 * [|Stage 2 care plan elements.xlsx] || Eva Powell || 06/03/11 ||  ||
 * [|ONC_ToC_Care Planning_SWG_Meeting Agenda_042111.docx] || Amy Berk || Apr 22, 2011 07:53 ||  ||
 * [|ONC_UCR_Care-Planning-Sub-WG meeting- 04-21-11..docx] || Amy Berk || Apr 22, 2011 07:52 ||  ||
 * [|ONC_UCR_Care-Planning-Sub-WG meeting- 04-14-11..docx] || Amy Berk || Apr 18, 2011 12:19 ||  ||
 * [|ONC_ToC_Care Planning_SWG_Meeting Agenda_041411.docx] || Amy Berk || Apr 14, 2011 15:42 ||  ||
 * [|ONC_UCR_Care-Planning-Sub-WG meeting- 04-12-11..docx] || Amy Berk || Apr 13, 2011 13:44 ||  ||
 * [|PPOC Use Case.doc] || Gregory L. Smith || Apr 12, 2011 16:54 || Sample User Story ||
 * [|Perinatology StoryBoard.docx] || Gregory L. Smith || Apr 12, 2011 16:54 || Sample User Story ||
 * [|Home Health Story Board.docx] || Gregory L. Smith || Apr 12, 2011 16:53 || Sample User Story ||
 * [|eNS storyboards diagrams.doc] || Gregory L. Smith || Apr 12, 2011 16:53 || Sample User Story ||
 * [|Diabetic Story Board.docx] || Gregory L. Smith || Apr 12, 2011 16:53 || Sample User Story ||
 * [|CarePlanPneumoniaStoryboard.doc] || Gregory L. Smith || Apr 12, 2011 16:53 || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px;">Sample User Story ||
 * [|Care coordination usecases v-9 (2).doc] || Gregory L. Smith || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Apr 12, 2011 16:53 || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px;">Sample User Story ||
 * [|Allergy and Intolerance Storyboard.docx] || Gregory L. Smith || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Apr 12, 2011 16:53 || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px;">Sample User Story ||
 * [|ONC_ToC_Care Planning_SWG_Meeting Agenda_041211.docx] || Amy Berk || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Apr 12, 2011 12:48 ||  ||
 * [|survey-4-30-10.pdf] || Ed Larsen || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 22, 2011 16:25 || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px;">This is the nursing survey form Audrey Dickerson ||
 * [|ONC_UCR_Care-Planning-Sub-WG meeting- 03-18-11..docx] || Amy Berk || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 19, 2011 10:35 ||  ||
 * [|HL7 CP ONC coordination.pptx] || Amy Berk || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 19, 2011 10:33 ||  ||
 * [|IHE_PCC_Query_for_Existing_Data_QED_Supplement_TI_2008-08-22.pdf] || Gregory L. Smith || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 17, 2011 16:35 ||  ||
 * [|Diabetic Story Board.docx] || Gregory L. Smith || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 17, 2011 16:35 ||  ||
 * [|HITSP_V1.0_2010_C154_-_Data_Dictionary.pdf] || Gregory L. Smith || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 17, 2011 16:34 ||  ||
 * [|Sample Home Care Services Instructions.docx] || Gregory L. Smith || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 16, 2011 15:34 ||  ||
 * [|Careplan2_IntermountainHealthCare.pdf] || Gregory L. Smith || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 16, 2011 15:27 ||  ||
 * [|CarePlan_IntermountainHealthCare.pdf] || Gregory L. Smith || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 12, 2011 11:53 || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px;">Draft of Care Plan Sub Workgroup content ||
 * [|Meaningful Use Stage 1 Final Rule The White Board Story_Version 1_July 28 2010_PRINT FINALv4_42x60.pdf] || Amy Berk || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 11, 2011 19:50 ||  ||
 * [|ONC_UCR_Care Planning Sub-WG meeting 03-10-11_Final.docx] || Amy Berk || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 11, 2011 19:49 ||  ||
 * [|HITSP_V0.0.1_2010_C162_-_Plan_of_Care[1.pdf]] || Ed Larsen || <span style="font-family: Helvetica,Arial,sans-serif; line-height: 17px; white-space: nowrap;">Mar 11, 2011 13:36 ||  ||

Draft working document for Care Plan Sub Workgroup (3/12/2011).
The purpose of the Care Planning Sub-Workgroup is to develop more detailed User Stories for Care Planning to include data elements that are to be included as part of Care Planning documentation. Care Planning involves both the patient and healthcare team and is used to develop a plan of action that leads to improved patient well-being.

Works in Progress:

 * **Artifact** || **Format** || **Date Posted** || **Comments Due Date** || **Status** || **Date Consensus Process**
 * Was Completed** || **Notes** ||
 * Care Planning in Meaningful Use || Text || 03/12/11 ||  || **OPEN** ||   ||   ||
 * Definition of Care Planning || Text || 03/12/11 ||  || **OPEN** ||   ||   ||
 * Comparison of Discharge Instruction to Care Plan || Text || 03/12/11 ||  || **OPEN** ||   ||   ||
 * Examples and other Care Planning Workgroups Considered || Text || 03/12/11 ||  || **OPEN** ||   ||   ||
 * User Story for Care Planning || Text || 03/12/11 ||  || **OPEN** ||   ||   ||
 * Consolidated CCD Sections and Data Fields || Text || 03/12/11 ||  || **OPEN** ||   ||   ||

1.0 Care Planning in Meaningful Use
Source: DEPARTMENT OF HEALTH AND HUMAN SERVICES. Office of the National Coordinator for Health Information Technology. Health Information Technology; HIT Policy Committee: Request for Comment Regarding the Stage 2 Definition of Meaningful Use of Electronic Health Records (EHRs)
 * ===**MU Category**=== || ===**Improving Quality, Safety, Efficiency & Reducing Health Disparities**=== ||  ||   ||
 * **Stage 1 Final Rule** || **Proposed Stage 2** || **Proposed Stage 3** || **Comments** ||
 * Maintain problem list (80%) || Continue Stage 1 || 80% problem lists are up-to-date || Drive list to be up to date by making it part of patient visit summary and care plans ||
 * ===MU Category=== || ===Engage Patients and Families in Their Care=== ||  ||   ||
 * **Stage 1 Final Rule** || **Proposed Stage 2** || **Proposed Stage 3** || **Comments** ||
 * Provide clinical summaries for each office visit (EP) (50%) || Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in a uniformly human readable form by 2013 (HITSC to define; e.g., use of PDF or text) || Patients have the ability to view and download relevant information about a clinical encounter within 24 hours of the encounter. Follow-up tests that are linked to encounter orders but not ready during the encounter should be included in future summaries of that encounter, within 4 days of becoming available. Data are available in a uniformly human readable form by 2015 (HITSC to define; e.g., use of CCD or CCR) || "Uniformly" implies HITSC should pick a single standard for human readable and a single standard for structured. The following data elements about the encounter are included (where relevant): encounter date and location; reasons for encounter; provider; problem list; medication list; medication allergies; procedures; immunizations; vital signs; diagnostic test results; clinical instructions; orders: future appointment requests, referrals, scheduled tests; gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. ||
 * Provide timely electronic access (EP) (10%); || Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in a uniformly human readable form by 2013 (HITSC to define; e.g., use of PDF or text). || Patients have the ability to view and download (on demand) relevant information contained in the longitudinal record, which has been updated within 4 days of the information being available to the practice. Patient should be able to filter or organize information by date, encounter, etc. Data are available in a uniformly structured form by 2015 (HITSC to define; e.g., use of CCD or CCR). || "Uniformly" implies HITSC should pick a single standard for human readable and a single standard for structured. The following data elements are included: encounter dates and locations; reasons for encounters; providers; problem list; medication list; medication allergies; procedures; immunizations; vital signs; diagnostic test results; clinical instructions; orders; longitudinal care plan; gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. ||
 * ===MU Category=== || ===Improve Care Coordination=== ||  ||   ||
 * **Stage 1 Final Rule** || **Proposed Stage 2** || **Proposed Stage 3** || **Comments** ||
 * Perform medication reconciliation (50%) || Medication reconciliation conducted at 80% of care transitions by receiving provider (transitions from another setting of care, or from another provider of care, or the provider believes it is relevant) || Medication reconciliation conducted at 90% of care transitions by receiving provider ||  ||
 * Provide summary of care record (50%) || Move to Core || Summary care record provided electronically for 80% of transitions and referrals ||  ||
 * (NEW) || List of care team members (including PCP) available for 10% of patients in EHR || List of care team members (including the PCP) available for 50% of patients via electronic exchange ||  ||
 * (NEW) || Record a longitudinal care plan for 20% of patients with high\- priority health conditions || Longitudinal care plan available for electronic exchange for 50% of patients with high-priority health conditions || What elements should be included in a longitudinal care plan including: care team members; diagnoses; medications; allergies; goals of care; other elements? ||

**2.0 Definition of Care Planning** Care planning includes strategies designed to guide health care professionals, the patient and the patient’s designees in the care of the patient and serves as a communications tool between these individuals. Such plans are patient centric, multidisciplinary, conceived with patient input, and coordinated by the patient’s PCP (when the patient is in the ambulatory environment and attending of record in the hospital/long term care).. Care plans are intended to ensure optimal outcomes for patients during the course of their care.

The care plan is an important element of coordination of care for patients with chronic diseases or complex clinical needs and is holistic, encompassing the medical conditions, social situation, and wellness goals of the patient. It typically includes long term goals and may also include short term goals. This is in contrast to hospital discharge instructions, which typically are more focused around the reasons for the hospitalization and have shorter term goals.

Effective care planning enabled by EHR technology will require an effective care plan document, and the exchange of the needed patient information to inform the plan. That master care plan document would typically be maintained dynamically in the EHR system of the primary care practice. It would serve as the equivalent of a musical score for orchestrating care coordination for individual patients.

The concept of such a care plan is described in models for patient centered medical homes as a holistic care plan that is created for complex (usually referred to as high risk) patients. It is a longitudinal care plan, as opposed to the daily care plans constructed for hospital inpatients, that is created by the collaborative efforts of the members of the patient’s care team of a practice in cooperation with the patient, and the patient’s family or designee(s).

The clinical summaries that are part of transitions of care serve as adjuncts to the care plan. The data in those clinical summaries, such as findings and relevant test results, serve to inform the care plan when assessments are made in order to build and maintain the dynamic care plan. The analogy would be the hospital discharge summary serving as an adjunct to hospital discharge instructions. The clinical summary documents are snapshots representing the state at the time of a transition of care. The master care plan however is a dynamic document that is expected to change and be updated, both as a result of periodic assessment of a patient's status and progress and as a result of unexpected events such as hospitalization.

The vision of interoperable care plans would enable hospital discharge instructions and recommendations by specialists after evaluation of a patient to be exchanged between systems in order to update the master care plan residing with the PCP. Hospital discharge instructions are in effect a longitudinal plan for a patient's care with a narrow focus and short timeframe related to the reasons for hospitalization. There is a need to update or modify elements of the master care plan with hospital discharge instructions, specialists’ recommendations, and recommendations from others outside the PCP practice; thus the need for specification of standards for interoperability around care plan data elements, as well as care summary data elements. Some of these data elements, such as goals, are unique to care plans. Others, such as patient education or patient instruction, are typical of care plans and there is a need to move toward specifying standards for structured data elements representing these types of interventions.

There is also a need to work towards creating interoperability between the care plan documents in EHR systems and PHRs in order to enable exchange of patient self-management plans with those PHRs.

Currently, CCR and CCD standards contain Care Plan sections, used in discharge instructions. These would be the first steps in creating interoperability around care plans. But the vision of continuous process improvement around coordination of care and transitions of care will require a roadmap for more robust interoperability between systems around care plan elements.

The following roles are significant to understanding care planning.

<span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">Care Manager/Navigator/Nurse ||< Healthcare professional with responsibilities regarding the patient care plan activities that include assessment (identifying patient needs), intervention (addressing patient needs), and evaluation (validating the effectiveness of the care plan) with members of the care team and the patient. ||
 * < **Care Team Role** ||< **Description** ||
 * < <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">Patient ||< <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">The patient who is the subject of the care plan. The patient participates in the creation of the care plan. Participates in monitoring, implementation and contribution to the plan as well as reviewing the goals. ||
 * < <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">Patient Designee ||< Where applicable. The monitoring, implementation and contribution to the plan may include the caregiver designated by the patient or legal designee.  ||
 * < <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">Care Team Lead ||< <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">PCP, or their delegate, in the ambulatory environment or the attending physician of record in the hospital or long term care environments ||
 * < <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">Primary Care Provider ||< <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">The Care Team's steward for the care plan and who is ultimately accountable for relevant clinical decision making and care coordination in regards to the patient’s care. ||
 * < <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">(maybe break into two roles)
 * < <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">Specialist, Other Providers, other care professionals ||< <span style="color: black; font-family: Calibri,sans-serif; font-size: 11pt; line-height: 13pt; margin: 7.5pt 0in;">Contributors of specific clinical information and recommendations about the patient and specific aspects of the care plan. Such contributions are to ultimately be coordinated for inclusion in the care plan by the PCP, or their delegate. ||

** Care planning within the context of Meaningful Use: **

Patient care planning should be holistic. The PCP, as the lead of the patient’s care team is responsible for the coordination of the Care Plan. Changes to the holistic [care] plan in an EHR or a management system are made by the Care Team. Care specific data (meds, allergies, etc.) may be added by other Providers, or care team members, but the care plan coordination and finalization is the responsibility of the PCP or the delegated Care Team Lead (e.g. Nurse Care Manager or other case manager).


 * Focus should be on quality outcomes and the Care Team is working towards those outcomes. The Care Team is accountable for the outcomes. Care coordination is central to reaching these outcomes. The patient is engaged in achieving these outcomes.
 * Enhanced care coordination among the care team.

3.0 Characteristics of Care Planning
The following table summarizes characteristics of care planning that impact transitions of care.

· Across the entirety of the Care Team including the patient and patient designee (where applicable). · Based on the patient's condition there may be multiple providers and care givers who are providing care. · In a dynamic care environment there is a desire to identify a PCP, or their delegate, as a coordinator of the care provided. || · Comprehensive or partial view of the care plan as appropriate. Such as diabetic patient being referral to a podiatry specialist and receiving portions of the care plan that pertain. || 2. Comprehensive including all of the patients’ conditions. || 4. For those patients who are required to have a care plan. 5. A care plan is typically used for patients with complex clinical needs and one or more chronic illnesses; becomes necessary in unique ways for unique patients (most likely to see cost savings; b/c multiple owners of the care being delivered; a multi-disciplinary approach). Sample triggers: A significant characteristic of care planning is the underlying process that is designed to coordinate care and engage providers as well as the patient in addressing patient centered outcomes. The following two figures were borrowed from the HL7 and IHIE care planning work as developed by Stephan Chu as an illustration of the intentions within the care planning process. In later sections the SWG identified a roadmap to developing the infrastructure components to support this care planning process.
 * ** Care Perspective ** |||| Prospective ||
 * ** Prepared By ** |||| Inter-disciplinary Care Team. Patient and patient designee (where applicable) are participants in preparing. ||
 * ** Integrated ** |||| · care plan is describe across members of the care team and problems  ||
 * ** Interoperable ** |||| · care plan can be exchanged between EHR systems  ||
 * ** Dynamic ** |||| · Reviewed and updated periodically, with the period depending on the individual patient, and reviewed when there is a significant event or change in the patient’s course or social situation.
 * ** Static ** |||| · Snapshot of a care plan or a picture in time of a care plan. Such as, at the time a patient is referred to a specialist or is admitted from a hospital to a long term care facility.
 * ** General Content ** |||| Patient centered medical home driven. Evidence based. Could be focused on quality ||
 * || ** Chronic condition specific ** ||  ||
 * || ** Acute ** ||  ||
 * || ** Sub Acute ** ||  ||
 * || ** Wellness ** || Preventative (screenings, etc.), health promotion (education, etc.), general health (smoking cessation), risk assessment or situational analysis (investigative) ||
 * || ** Education ** || In each area of content. ||
 * ** Focus ** |||| 1. Patient Centric
 * ** Who would Have ** |||| 3. Not necessary for every patient.
 * 1) Nature of the illness (e.g. disease specific CM programs such as oncology)
 * 2) Severity of illness
 * 3) Frequency of hospitalization
 * 4) Length of hospitalization(s)
 * 5) The patient’s recognized or expressed need for assistance with other services (e.g. housing, transportation, therapies, etc.) ||
 * ** Measurement of goals ** |||| Complex measurement of goals. Tied to an intervention. Before and after comparison is targeted. Adjust based on progress between before and after measurement ||

Care Planning Conceptual Foundation:

Care Planning Application of the Process

4.0 Examples and other Care Planning Workgroups Considered
Care planning is the focus of several national groups. To insure that the efforts of the Care Planning Sub Workgroup result in useful information the following table lists the information that guided the group's efforts.
 * The HL7 and IHE care planning work is moving forward in the Patient Care TC in HL7 with 2 co-chairs for this topic. Laura H Langford Laura.Heermann@imail.organd Andre Boudreau a.boudreau@boroan.ca. the group has been meeting for several weeks and is moving forward quickly. I can check with either to see when/if a presentation on the current work can be done.
 * The Object Management Group meeting is the week of 3/20/11 in Crystal City, VA. If you like, I can approach their leadership to see if they could help me reach out to participating vendors for what (like their organization) is, effectively, an “open-source” project.
 * Vendors like McKesson should be participants as they have been in this market for many years. I think virtually all the major HIT vendors participate in OMG, a Standards Development Organization (SDO).
 * OMG takes the BPM/SOA approach to E.H.R and is “open source.” I will also ask HL7 experts at Deloitte whether CM, DM modules already exist there. OMB and HL7 have established a collaborative relationship.


 * **Organization** || **Care Plan (actual examples in upload section)** || **Notes** ||
 * Intermountain Healthcare || General format to define a care plan. || None ||

5.0 User Story for Care Planning
Care planning is a complex activity that potentially involves a multi-disciplinary team including a patient and caregivers managing one or more chronic conditions. Care planning is an important aspect to Patient-Centered Medical Home, Accountable Care Organizations, and other transformative concepts. The ONC Direct Project only skimmed the surface of the user story for care planning as described in the following user story.

There are two user stories provided. The first user story describes the foundation to care planning. The second user story is a more complex example.

User Story 1: Foundational Care Planning where care plan is established and patient progresses through the plan.
At the beginning of the User Story the patient has an initial care plan. Throughout the user story an as a result of subsequent events or scheduled activities this care plan evolves to include additions and modifications of the care plan. The user story illustrates the dynamic nature of a care plan which is managed by the patient and providers. · Reviewed and updated periodically, with the period depending on the individual patient, and reviewed when there is a significant event or change in the patient’s course or social situation. · Across the entirety of the Care Team including the patient and patient designee (where applicable). · Based on the patient's condition there may be multiple providers and care givers who are providing care. · In a dynamic care environment there is a desire to identify a PCP, or their delegate, as a coordinator of the care provided. || Mental Health Supplement ||^  ||
 * **Based on S&I ToC User Story** ||  || **Activity** ||= **Interoperability to Care Plan** (see roadmap of data elements below in section 6.0 as well as ToC dataset functional requirements) ||= **Dynamic Care Plan** (see roadmap of data elements below in section 6.0) ||
 * Closed-Loop Referral || →→ || 1. Patient and Care Team develop initial, comprehensive care plan. (see Setting 1(a)). ||  || [[image:http://www.futurekansas.com/images.jpg width="162" height="150" align="center"]]
 * Federated Care Plan **
 * ^  ||^   ||^   ||= <span style="display: block; font-family: calibri,sans-serif; font-size: 11pt; line-height: 115%; margin-bottom: 0in; text-align: center;">Initial Patient Centered Care Plan [[image:http://www.futurekansas.com/arrow.jpg]]
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * ||  || 2. The patient supplements the care plan with a self care plan. (see Setting 2) ||   ||^   ||
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * ||  || 3. Patient visits pharmacy where medication is filled and pharmacist re checks for drug-drug interactions (this having already been done by the physician in her EHR at the time of CPOE) as well as reinforces education. (see Setting 3) ||   ||^   ||
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * Closed-Loop Referral || →→ || 4. Patient encounter with the Care Team Member asthma specialist which was scheduled as part of original care plan. (see Setting 4) || [[image:http://www.futurekansas.com/arrow.jpg]]Clinical Summary with Consultation Note ||^  ||
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * ||  || 5. Patient returns to the Care Team Lead/PCP for a scheduled follow-up visit according to the initial care plan. The Care Team Lead is able to review adherence to the care plan with the patient. (see Setting 1(b)) ||   ||^   ||

The following diagram provides a contextual illustration for the various participants in the foundational care planning user story.



The user story describes transitions among the members of the Care Team as well as the patient. The following diagram summarizes the interactions as well as a general illustration of the data to be exchanged.




 * Actors:**
 * Patient – a moderately obese patient with asthma
 * Patient Designee - (e.g. DPOA-HC)
 * Primary Care Physician (PCP)
 * Care Team Lead/PCP (creator of care plan)
 * Nurse
 * Care Manager/Navigator/Nurse
 * Care team – health care providers addressing the patient's current problem list
 * Referrer – (Care Team Lead/PCP)
 * Other Specialist Providers – various health services or professionals receiving a referral and the care plan to treat patient, such as (Care Team Member)


 * Setting 1(a): Care Team Lead/PCP’s or Patient's Care Team **

The patient, a moderately obese patient with asthma, attends the HealthyLIfe medical center and is diagnosed with type II diabetes by his PCP. After commencing treatment with dietary and appropriate exercise recommendations and initial patient education, a care plan is developed to support both healthcare and follow-up for this complex problem. In addition to having diabetes the patient is also depressed and drinking more than the recommended allowance of alcohol for an otherwise healthy person due to pressures of work and recent marriage.

The PCP, in the role of Care Team Lead, develops a care plan in consultation with the care team and patient, using current best practice guidelines. This care plan focuses on appropriate management of the patient’s newly diagnosed diabetes as well as the patient's other chronic conditions (described in the problem list), such as asthma, depression, excessive ETOH intake, etc. The Care Team Lead/PCP also recommends (a referral is made) that the patient see a psychologist working in the same health center to address the depression and alcohol intake. The Care Team Lead/PCP discusses the patient's case with the psychologist and Care Team Member. The psychologist decides that a multidisciplinary approach is necessary and creates a mental health portion of the care plan. The following summarizes the content of the care plan and the specific care plan is shown on the following pages.

The care plan lists the members of the care team covering the name of the healthcare provider (if known), their role, and the service that covers this person and role.

The content of the care plan includes a schedule of tasks that are to be performed by the patient, by the doctor and by other health care providers (the care team.) In this patient’s case the diabetes care team consists of a nurse, diabetes educator, a dietician, a podiatrist, an asthma specialist, an optometrist, a pharmacist. For the mental healthcare plan the care team consists of the psychologist, the PCP and drug/alcohol counselor.

Encounters with the care team are scheduled in the plan with indicated date.

<span style="font-family: Calibri,sans-serif; font-size: 11pt;">Bob Glucose is provided with a care plan prepared by a multi-disciplinary team. Care plan data should be computable and coded for use in quality measures. The care plan can be fully coded in Clinical Care Classification (CCC) National Nursing Terminology Standard recognized by HITSP 2006. MEDCIN is nomenclature mapping to the major medical terminologies: ICD, CPT, LOINC, SNOMED, RxNORM, as well as the Clinical Care Classification Standard. Also included the MEDCIN identifier for each CCC concept in the Care Plan. The care plan focuses on the two current problems covering: 1. Diabetes management and prevention 2. Mental Health

The patient's diabetes care plan looks like this:

**Patient: Mr Bob Glucose Gender Male DOB 11/6/1950 Purpose of plan : Diabetes management** Target: Patient has received education Nursing Diagnosis: Endocrine Alteration (I22.0) MEDCIN ID: 314442 Goal: Improve Endocrine Alteration (I22.0.1) Nursing Intervention: Diabetic Care (I27.0) MEDCIN ID: 305047 || Diabetes education Teach Diabetic Care (I27.0.3) MEDCIN ID: 307054 Signs of hyperglycemia Use of glucometer || Ms B. Well, RN (Nurse / Diabetes Educator) || Weekly x 2 6 months Every year ||  || ue Sep 2009 || Needs interpreter || Target: Patient maintaining healthy diet Nursing Diagnosis: Body Nutrition Excess (J24.3) MEDCIN ID: 314413 Goal: Stabilize Body Nutrition Excess (J24.3.2) Nursing Intervention: Nutrition Care (J29.0) MEDCIN ID: 305015 Special Diet (J29.4) MEDCIN ID: 305018 || Nutrition education || Mr. E. Better (Nutritionist / Dietitian) || Weekly x 2 || 11 Dec 2008 || Due Dec 2010 ||  || Teach Nutrition Care (J29.0.3) MEDCIN ID: 37099 Teach Special Diet (J29.4) MEDCIN ID: 307100 Online resource support || Designated by Care Team || Every year || 5 Feb 2009 || Due Feb 2010 ||  || Target: 30 Minutes per day of selected exercise 5 days per week Nursing Diagnosis: Individual Coping Alteration (E12.0) MEDCIN ID: 314361 Goal: Improve Individual Coping (E12.0.1) Nursing Intervention: Stress Control (E12.2) MEDCIN ID: 304971 || Physical activity education Teach Stress Control (E12.2.3) MEDCIN ID: 305881 || Ms B. Well, RN Nurse || 6 months || 11 Dec 2008 || Due Dec 2010 ||  || Target: Weight ≤ 80.0 kg Nursing Diagnosis: Knowledge Deficit (D08.0) MEDCIN ID: 314346 Goal: Improve knowledge deficit (D08.0.1) Nursing Intervention: Activity Care (A01.0) MEDCIN ID: 304991 || Body weight assessment and counseling Teach Activity Care (A01.0.3) MEDCIN ID: 306936 || Mr. E. Better (Dietitian) || Every 2 years || 11 Dec 2008 || Due Dec 2010 ||  || Target: Complete cessation Nursing Diagnosis: Tobacco Abuse (N58.1) MEDCIN ID: 314330 Goal: Improve Tobacco Abuse (N58.1.1) Nursing Intervention: Tobacco Abuse Control (N40.1) MEDCIN ID: 34931 || Counseling Teach tobacco abuse control (N40.1.3) MEDCIN ID: 306335 || Ms B. Well (Nurse/PCP) || Every year || 11 Dec 2008 || Due Dec 2009 ||  || Target: ≤ 1 Standard Drinks per day Nursing Diagnosis: Alcohol Abuse (N58.2) MEDCIN ID: 314331 Goal: Improve Alcohol Abuse (N58.2.1) Nursing Intervention: Alcohol Abuse Control (N40.2) MEDCIN ID: 304932 || Alcohol consumption education and counseling Teach alcohol abuse control (N40.2.3) MEDCIN ID:3017234 Online resource support || Ms B. Well (Nurse/PCP ) || Every 2 years || 11 Dec 2008 || Due Dec 2010 ||  || Target: Blood Pressure < 130/80 mm/Hg Nursing Diagnosis: Blood Pressure Alteration (C06.1) MEDCIN ID: 314494 Goal: Improve Blood Pressure Alteration (C06.1.1) Nursing Intervention: Blood Pressure (K33.1) MEDCIN ID: 305062 || Measure blood pressure Assess Blood Pressure (K33.1.1) MEDCIN ID:307180 Measure Blood Pressure (K33.1.2) MEDCIN ID: 306357 Teach Blood Pressure (home monitoring) (K33.1.3) MEDCIN ID:307822 || Care Team || Every 6 months || 17 Dec 2008 || Due Jun 2009 ||  || Target: HDL ≥ 1.0 mmol/L, LDL < 2.0 mmol/L, Total Cholesterol < 4.0 mmol/L, Triglycerides < 1.5 mmol/L Nursing Diagnosis: Cardiovascular Alteration (C06.0) MEDCIN ID: 314436 Goal: Improve Cardiovascular Alteration (C06.0.1) Nursing Intervention: Specimen Care (K32.0) MEDCIN ID: 305056 || Order lipids test Perform Specimen Care (K32.0.2) MEDCIN ID: 307149 || Designated by Care Team || Every year || || Due Sep 2009 ||   || Target: Blood Sugar Level < 7.0 mmol/L, HbA1c ≤ 7.0% Nursing Diagnosis: Endocrine Alteration (I22.0) MEDCIN ID: 314442 Goal: Improve Endocrine Alteration (I22.0.1) Nursing Intervention: Blood Specimen Care (K32.1) MEDCIN ID: 305057 || Measure HbA1c Perform Blood Specimen Care (K32.1.2) MEDCIN ID: 307150 || Designated by Care Team || Every 6 months || || Due Sep 2009 ||   || Target: Albumin Creatinine Ratio < 2.5 mg/mmol, GFR > 60 ml/min/1.73², Microalbumin < 20 µg/min timed overnight collection, < 20 mg/L spot collection Nursing Diagnosis: Endocrine Alteration (I22.0) MEDCIN ID: 314442 Goal: Improve Endocrine Alteration (I22.0.1) Nursing Intervention: Urine Specimen Care (K32.3) MEDCIN ID: 305059 || Order microalbuminuria test Perform Urine Specimen Care (K32.3.2) MEDCIN ID: 307152 || Designated by Care Team || Every year || || Due Sep 2009 ||   || Target: Minimize eye damage Nursing Diagnosis: Endocrine Alteration (I22.0) MEDCIN ID: 314442 Goal: Improve Endocrine Alteration (I22.0.1) Nursing Intervention: Eye Care (Q50.0) MEDCIN ID: 305033 || Dilated Eye Exam Monitor eye care (Q50.0.1) MEDCIN ID: 307618 || No named provider – Optometry service || Every 2 years || 1 Apr 2009 || Due Apr 2011 ||  || Target: Minimize foot complications Nursing Diagnosis: Endocrine Alteration (I22.0) MEDCIN ID: 314442 Goal: Improve Endocrine Alteration (I22.0.1) Nursing Intervention: Foot Care (S56.0) MEDCIN ID: 305079 || Check feet Monitor foot care (S56.0.1) MEDCIN ID: 307694 || Dr. K. Toe (Podiatrist) || Every year || 11 Dec 2008 || Due Dec 2009 ||  || Target: Minimize adverse cardiovascular effects Nursing Diagnosis: Cardiovascular Alteration (C06.0) MEDCIN ID: 314436 Goal: Improve Cardiovascular Alteration (C06.0.1) Nursing Intervention: Cardiac Care (C08.0) MEDCIN ID: 305036 || Cardiovascular review Monitor Cardiac Care (C08.0.1) MEDCIN ID: 307000 || Designated by Care Team || Every year || 5 Feb 2009 || Due Feb 2010 ||  || Target: Reduced frequency of depressive episodes Nursing Diagnosis: Alteration (P42.0) MEDCIN ID: 314388 Goal: Improve Meaningfulness Alteration (P42.0.1) Nursing Intervention: Counseling (E12.0) MEDCIN ID: 304969 || Psychological assessment Refer Counseling Service (E12.0.4) MEDCIN ID: 306525 || Ms E. Thierry (Psychologist) || Every year || 11 Dec 2008 || Due Dec 2009 ||  || Target: Reduced frequency of asthma episodes Nursing Diagnosis: Respiratory Alteration (L26.0) MEDCIN ID: 314437 Goal: Improve Respiratory Alteration (L26.0.1) Nursing Intervention: Pulmonary Care (L36.0) MEDCIN ID: 305040 || Asthma assessment Assess pulmonary care (L36.0.1) MEDCIN ID: 307190 Manage pulmonary care (L36.0.4) MEDCIN ID: 307210 || Dr. Asthma (Asthma specialist) || Every year || 11 Dec 2008 || Due Dec 2009 ||  || Target: Minimize incidents of misuse of medications Nursing Diagnosis: Endocrine Alteration (I22.0) MEDCIN ID: 314442 Goal: Improve Endocrine Alteration (I22.0.1) Nursing Intervention: Medication Side Effects (H24.3) MEDCIN ID: 304927 Nursing Intervention: Medication Actions (H24.1) MEDCIN ID: 304925 || Medication review Teach medication side effects (H24.3.3) MEDCIN ID: 305196 Teach proper use of medications (H24.1.3) MEDCIN ID: 307048 || Designated by Care Team || Every year || 5 Feb 2009 || Due Feb 2010 ||  ||
 * **Goal** || **Task** || **Provider** || **Frequency** || **Last** || **Next** || Comment ||
 * **Clear understanding of diabetes**
 * ^  || Diabetes education review || Designated by Care Team || Every year || 5 Feb 2009 || Due Feb 2010 ||   ||
 * **Maintain healthy diet**
 * ^  || Nutrition review
 * ^  || Nutrition self management || Patient || Ongoing ||   || Ongoing ||   ||
 * **Maintain physical well-**
 * ^  || Physical well-being management review || Dr Planner (Care Team Lead/PCP) || Every year || 5 Feb 2009 || Due Feb 2010 ||   ||
 * ^  || Physical well-being self management || Patient || Ongoing ||   || Ongoing ||   ||
 * **Manage body weight**
 * ^  || Review body weight || Dr Planner (Care Team Lead/PCP) || Every year || 5 Feb 2009 || Due Feb 2010 ||   ||
 * ^  || Body weight self management || Patient || Ongoing ||   || Ongoing ||   ||
 * **Cease smoking**
 * ^  || Smoking review || Designated by Care Team || Every year || 5 Feb 2009 || Due Feb 2010 ||   ||
 * ^  || Action plan (cease smoking) || Patient || Ongoing ||   || Ongoing ||   ||
 * **Manage alcohol consumption**
 * ^  || Alcohol review || Psychologist || Every 6 months || 5 Aug 2009 || Due Feb 2010 ||   ||
 * ^  || Alcohol consumption self management || Patient || Ongoing ||   || Ongoing ||   ||
 * **Control blood pressure**
 * **Control lipids**
 * **Control blood glucose**
 * ^  || Measure blood glucose || Designated by Care Team || Every 3 months || 17 Dec 2008 || Due Mar 2009 ||   ||
 * ^  || Measure blood glucose || Patient || Ongoing || [[image:file:///C:/Users/GREGSM~1/AppData/Local/Temp/msohtmlclip1/01/clip_image001.gif width="32" height="32"]] || Ongoing ||   ||
 * **Avoid renal complications**
 * ^  || Order serum creatinine test || Designated by Care Team || Every year || [[image:file:///C:/Users/GREGSM~1/AppData/Local/Temp/msohtmlclip1/01/clip_image001.gif width="32" height="32"]] || Due Sep 2009 ||   ||
 * **Avoid eye complications**
 * ^  || Eye check || Designated by Care Team || Every 2 years || 5 Feb 2009 || Due Feb 2011 ||   ||
 * **Avoid foot complications**
 * ^  || Foot care education || Ms B. Well (Diabetes Educator) || Every 2 years || 11 Dec 2008 || Due Dec 2010 ||   ||
 * ^  || Check feet || Designated by Care Team || Every 6 months || 5 Aug 2009 || Due Feb 2010 ||   ||
 * ^  || Check feet || Patient || Ongoing ||   || Ongoing ||   ||
 * **Avoid cardiovascular complications**
 * ^  || Self-manage cardiovascular risk factors || Patient || Ongoing ||   || Ongoing ||   ||
 * **Reduce depressive episodes**
 * **Reduce asthma episodes**
 * **Correct use of medications**

The diabetes care plan was flagged as having a standard level of confidentiality rating (i.e. accessible to any authorized healthcare practitioner involved in the patients care)

The following tasks were allocated by the psychologist covering Mental Health issues.

There is a specialized portion of the care team for this issue and because of the nature of the problem the confidentially status of documents relating to this problem is at a higher level (available only via members of the care team). The care plan document is shared among the patient's Care Team based on the security of the care and is coordinated by Care Team Lead/PCP and/or the Case Manager/Navigator/Nurse.

**Patient: Mr Bob Glucose Gender Male DOB 11/6/1950 Purpose of plan : manage depression and alcohol dependence**
 * **Goal** || **Task** || **Provider** || **Frequency** || **Last** || **Next** || **Comment** ||
 * Manage Depression || Assessment and report || Ms Jane Insight, Psychologist || 3 monthly ||  || 24/1/2010 ||   ||
 * Alcohol abstention || Order referral to gastroenterologist for assessment of liver damage || Dr. Planner, Dr. Gastroenterologist || Once ||  || 12/1/2010 ||   ||
 * ^  || Counseling || New Farm, Alcohol and Drug Counseling Servicer || 6 monthly ||   || 24/1/2010 ||   ||
 * ^  || Counseling || New Farm, Alcohol and Drug Counseling Servicer || 6 monthly ||   || 24/1/2010 ||   ||

The care plan is documented in the Care Lead/PCP's EHR system as well as the psychologist's EHR system. Within the EHR the Care Team Lead/PCP or the Case Manager/Navigator/Nurse prepares the consultation request clinical summary to the specialists described in the care plan including those who are Care Team Members. The message is addressed to the appropriate specialist, specialty or provider organization and is sent to the specialist’s EHR system. The Care Team Lead/PCP sends the consultation request clinical summary and care plan to the patient's PHR system. Care Team Lead/PCP asks the patient to make appointments with the providers identified in the plan.


 * Setting 2: Patient**

Activity: The patient returns home after the visit with the Care Team Lead/PCP. The patient uses his PHR system to document activities within his self care plan based on the discussion with the Care Team Lead/PCP. The patient's self care plan supplements the clinical summary and care plan received from the Care Team Lead/PCP.


 * Setting 3: Pharmacy**

Activity: The patient arrives at the pharmacy to pick up a prescription eprescribed from the Care Team Lead/PCP's EHR system. The pharmacist reviews any drug-drug or drug-food interactions with the patient and reinforces education.


 * Setting 4: Care Team Member Asthma Specialist’s office (from Closed Loop Referral user story)**

Activity: In accordance with practice policies and workflow the specialist reviews the document and orders any additional tests to be performed for the patient prior to the office visit. Discrete data elements from within the summary may be promoted to the specialist’s EHR system.

When the patient arrives at the asthma specialist's office he is registered in accordance with practice policies and workflow. The asthma specialist documents the encounter in the EHR system and prepares the consult summary to the Care Lead/PCP. Once the consult summary is prepared, it is addressed and sent to the Care Lead/PCP/Medical Home’s EHR system. A copy of the message is retained in the asthma specialist's EHR system. The PCP and the Care Team modify elements of the care plan based on specialist's recommendations.

The asthma specialist may also send the clinical summary with the consultation summary to the patient's PHR system.


 * Setting 1(b): Care Team Lead/PCP’s or Patient's Care Team office (from all user stories)**

Six months later, the patient visits the Care Team Lead/PCP for a regular review. Care Team Lead/PCP is able to access the various clinical summaries, consult summaries, discharge summaries and discharge instructions. Care Team Lead/PCP notes that there is no record of encounter with the optician. An exception report had also been created by the Case Manager/Navigator/Nurse and alerted the Care Team Lead/PCP after 1 months post the expected completion date. Care Team Lead/PCP counsels the patient on the risks of retinopathy and advises him to visit the optician for a check as soon as possible.

Care Team Lead/PCP may send the clinical summary and care plan to the patient's PHR system.

**User Story 2: Care Planning with an incident outside of defined care plan. **
At the beginning of the User Story the patient has an initial care plan. Throughout the user story an as a result of subsequent events or scheduled activities this care plan evolves to include additions and modifications of the care plan. The user story illustrates the dynamic nature of a care plan which is managed by the patient and providers. (Note: steps 1, 2, 3 and 9 are the same as the foundational user story)

· Reviewed and updated periodically, with the period depending on the individual patient, and reviewed when there is a significant event or change in the patient’s course or social situation. · Across the entirety of the Care Team including the patient and patient designee (where applicable). · Based on the patient's condition there may be multiple providers and care givers who are providing care. · In a dynamic care environment there is a desire to identify a PCP, or their delegate, as a coordinator of the care provided. || Mental Health Supplement ||^  || Clinical Summary with Consultation Note ||^  || Discharge Summary ||^  || Discharge Summary ||^  || Discharge Instructions ||^  || · Hospital Discharge || →→ || 7. Patient is discharged to rehab facility. (see Setting 7) || Clinical Summary ||^  || · Closed-Loop Referral || →→ || 8. Patient follows up with orthopedic surgeon following hospital stay (similar to Hospital Discharge user story). Additions are made to the patient's care plan. (see Setting 8) || Clinical Summary with Consultation Note ||^  ||
 * ** Based on S&I ToC User Story ** ||  || ** Activity ** ||= ** Interoperability to Care Plan ** (see roadmap of data elements below in section 6.0 as well as ToC dataset functional requirements) ||= ** Dynamic Care Plan ** (see roadmap of data elements in section 6.0) ||
 * Closed-Loop Referral || →→ || 1. Patient and Care Team develop initial, comprehensive care plan. (see Setting 1(a)). ||  || [[image:http://www.futurekansas.com/images.jpg width="162" height="150" align="center"]]
 * Federated Care Plan**
 * ^  ||^   ||^   || <span style="display: block; font-family: calibri,sans-serif; font-size: 8pt; line-height: 12px; margin-bottom: 0in; text-align: center;">Initial Patient Centered Care Plan [[image:http://www.futurekansas.com/arrow.jpg align="center"]]
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * ||  || 2. The patient supplements the care plan with a self care plan. (see Setting 2) ||   ||^   ||
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * ||  || 3. Patient visits pharmacy where medication is filled and pharmacist re checks for drug-drug interactions (this having already been done by the physician in her EHR at the time of CPOE) as well as reinforces education. (see Setting 3) ||   ||^   ||
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * Closed-Loop Referral || →→ || 4. Patient encounter with the Care Team Member asthma specialist which was scheduled as part of original care plan. (see Setting 4) Patient expresses new complaint during this encounter. The Care Team Member coordinates with Care Team Lead/PCP to refer outside of patient's Care Team and existing care plan to an orthopedic specialist (similar to Closed-Loop Referral user story). (see Setting 8) || [[image:http://www.futurekansas.com/arrow.jpg align="center"]]
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * Complex Series of Care || →→ || 5. Patient falls. Patient is taken to ED. (see Setting 5) || [[image:http://www.futurekansas.com/arrow.jpg align="center"]]
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * Complex Series of Care || →→ || 6. Patient is placed in hospital. (see Setting 6) || [[image:http://www.futurekansas.com/arrow.jpg align="center"]]
 * ||  ||^   || [[image:http://www.futurekansas.com/arrow.jpg align="center"]]
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * · Complex Series of Care
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="27" height="25" align="center"]] ||   ||^   ||
 * · Hospital Discharge
 * ||  || [[image:http://www.futurekansas.com/down-arrow.gif width="32" height="30" align="center"]] ||   ||^   ||
 * ||  || 9. Patient returns to the Care Team Lead/PCP for a scheduled follow-up visit according to the initial care plan. The Care Team Lead is able to review adherence to the care plan with the patient. (see Setting 1(b)) ||   ||^   ||

The following diagram provides a contextual illustration for the various participants in the complex care planning user story.



The user story describes transitions among the members of the Care Team, other providers as well as the patient. The following diagram summarizes the interactions as well as a general illustration of the data to be exchanged.




 * Actors:**
 * Patient – a moderately obese patient with asthma
 * Patient Designee - (e.g. DPOA-HC)
 * Primary Care Physician (PCP)
 * Care Team Lead/PCP (creator of care plan)
 * Nurse
 * Care Manager/Navigator/Nurse
 * Care team – health care providers addressing the patient's current problem list
 * Referrer – (Care Team Lead/PCP)
 * Other Specialist Providers – various health services or professionals receiving a referral and the care plan to treat patient, such as (Care Team Member) and (outside Care Team)


 * Setting 1(a): Care Team Lead/PCP’s or Patient's Care Team office**

The patient, a moderately obese patient with asthma, attends the HealthyLIfe medical center and is diagnosed with type II diabetes by his PCP. After commencing treatment with dietary and appropriate exercise recommendations and initial patient education, a care plan is developed to support both healthcare and follow-up for this complex problem. In addition to having diabetes the patient is also depressed and drinking more than the recommended allowance of alcohol for an otherwise healthy person due to pressures of work and recent marriage breakup.

The PCP, in the role of Care Team Lead, develops a care plan in consultation with the care team and patient, using current best practice guidelines. This care plan focuses on appropriate management of the patient’s newly diagnosed diabetes as well as the patient's other chronic conditions (described in the problem list), such as asthma, depression, excessive ETOH intake, etc. The Care Team Lead/PCP also recommends (a referral is made) that the patient, see a psychologist working in the same health center to address the depression and alcohol intake. The Care Team Lead/PCP discusses the patient's case with the psychologist and Care Team Member. The psychologist decides that a multidisciplinary approach is necessary and creates a mental health portion of the care plan. The following summarizes the content of the care plan and the specific care plan is shown on the following pages.
 * The care plan lists the members of the care team covering the name of the healthcare provider (if known), their role, and the service that covers this person and role.
 * The content of the care plan includes a schedule of tasks that are to be performed by the patient, by the doctor and by other health care providers (the care team.) In this patient’s case the diabetes care team consists of a nurse, diabetes educator, a dietician, a podiatrist, an asthma specialist, an optometrist, a pharmacist. For the mental healthcare plan the care team consists of the psychologist, the PCP and drug/alcohol counselor. Encounters with the care team are scheduled in the plan with indicated dates.

The patient is provided with a care plan prepared by a multi-disciplinary team. Care plan data should be computable and coded for use in quality measures. The care plan can be fully coded in Clinical Care Classification (CCC) National Nursing Terminology Standard recognized by HITSP 2006. MEDCIN is nomenclature mapping to the major medical terminologies: ICD, CPT, LOINC, SNOMED, RxNORM, as well as the Clinical Care Classification Standard. Also included the MEDCIN identifier for each CCC concept in the Care Plan. The care plan focuses on the two current problems covering:
 * 1) Diabetes management and prevention
 * 2) Mental Health

The patient's diabetes care plan is found in the Foundation Care Planning user story.

The diabetes care plan was flagged as having a standard level of confidentiality rating (i.e. accessible to any authorized healthcare practitioner involved in the patients care)

The tasks were allocated by the psychologist covering Mental Health issues and are found in the Foundation Care Planning user story.

There is a specialized portion of the care team for this issue and because of the nature of the problem the confidentiality status of documents relating to this problem is at a higher level (available only via members of the care team). The care plan document is shared among the patient's Care Team based on the security of the care and is coordinated by the Care Team Lead/PCP and/or the Case Manager/Navigator/Nurse.

The care plan is documented in the Care Lead/PCP's EHR system as well as the psychologist's EHR system. Within the EHR the Care Team Lead/PCP or the Case Manager/Navigator/Nurse prepares the consultation request clinical summary to the specialists described in the care plan including those who are Care Team Members. The message is addressed to the appropriate specialist, specialty or provider organization and is sent to the specialist’s EHR system. The Care Team Lead/PCP sends the consultation request clinical summary and care plan to the patient's PHR system. Care Team Lead/PCP asks the patient to make appointments with the providers identified in the plan.


 * Setting 2: Patient**

Activity: The patient returns home after the visit with the Care Team Lead/PCP. The patient uses his PHR system to document activities within his self care plan based on the discussion with the Care Team Lead/PCP. The patient's self care plan supplements the clinical summary and care plan received from the Care Team Lead/PCP.


 * Setting 3: Pharmacy**

Activity: The patient arrives at the pharmacy to pick up a prescription eprescribed from the Care Team Lead/PCP's EHR system. The pharmacist reviews any drug-drug or drug-food interactions with the patient and reinforces education.


 * Setting 4: Care Team Member Asthma Specialist’s office (from Closed Loop Referral user story)**

Activity: In accordance with practice policies and workflow the specialist reviews the document and orders any additional tests to be performed for the patient prior to the office visit. Discrete data elements from within the summary may be promoted to the specialist’s EHR system.

When the patient arrives at the asthma specialist's office he is registered in accordance with practice policies and workflow. The patient complains about pain in his left knee during his encounter with the asthma specialist. The asthma specialist prepares a secure message within the EHR to the Care Team Lead/PCP with a notification of the new problem. The Care Team Lead/PCP will prepare a consultation request clinical summary to an orthopedic specialist. The Care Team Lead/PCP message is addressed to the orthopedic specialist, specialty or provider organization and is sent to the specialist’s EHR system.

After notifying the Care Team Lead/PCP of the new problem, the asthma specialist continues to document the encounter in the EHR system and prepares the consult summary to the Care Lead/PCP [I would imagine that these (above and this) would be combined in the consult note]. Once the consult summary is prepared, it is addressed and sent to the Care Lead/PCP/Medical Home’s EHR system. A copy of the message is retained in the asthma specialist’s EHR system. The PCP and the Care Team modify elements of the care plan based on the specialist's recommendations.

The asthma specialist sends the consultation summary clinical summary and care plan to the patient's PHR system.


 * Setting 5: ED (from Complex Series of Care Transitions user story)**

Activity: The patient falls. The patient is transported to the ED from home in a semi-aware condition. His significant other has printed data from the patient’s PHR or sent a secure message from the PHR. The PHR patient summary has been given that to the EMS or to the ED doctor. Prior to leaving the house the patient’s significant other alerted the patient’s PCP that he was going to the ED (and specified the ED). The PCP sent a direct message patient summary that includes the care plan from Care Team Lead/PCP’s EHR system. The ED physician determines that the patient needs to be admitted to the hospital. The patient is admitted to the hospital from the ED. [I would assume that the ED is actually part of the hospital where the patient is admitted, and that the ED has the same EHR system or it is interfaced with the Hospital EHR system] [I think this is information overload, they would want this at the time of discharge, but would want to receive a notification of hospital admission – open for discussion] and may also be sent to the patient's PHR system.


 * Setting 6: Hospital (from Hospital Discharge and Complex Series user stories)**

Activity: The patient is admitted to the hospital and is cared for in a surgical unit. All treating clinicians have access to the information in the Hospital EHR system. His significant other has printed data from the patient’s PHR or sent a secure message from the PHR. The PHR patient summary has been provided to the hospital. The hospital's EHR system receives the patient summary that includes the care plan from Care Team Lead/PCP’s EHR system The care plan may be useful to the hospital to insure therapies are continued, such as his usual asthma medication and his SSRI for depression.

The patient’s significant other, who is the patient’s Durable Power of Attorney for Healthcare (DPOA-HC), is staying with the patient in the hospital. The patient’s DPOA-HC requests that copies of changes to patient’s orders be sent directly from the hospital EHR to the patient’s PHR so that he can monitor the patient’s care. After several days in the surgical care unit it is determined that the patient would benefit from intensive rehabilitation that is not available at the hospital. The attending physician arranges a discharge from the hospital and transfer for the patient to a Rehabilitation Facility. In accordance with the hospital’s policies and workflow a discharge summary and instructions are prepared by the hospital EHR. The discharge summary and instructions, including recommendations for continuation of open orders, are sent to the Rehab facility EHR. The hospital EHR sends patient’s Care Team Lead/PCP’s EHR a copy of discharge summary/instructions.

A patient is discharged from the hospital or ED. Discharge instructions are given to the patient by his nurse or care manager on day of discharge at or a short time before the physical discharge. The instructions may be generic, patient specific, or disease specific depending on the facility’s practices and the patient’s needs. The patient acknowledges that he has received the instructions from the nurse (verbally, in writing, and/or electronically). The acknowledgement triggers the physical discharge sequence of events and patient transport out of the facility. The discharge instructions are sent to the patient's Care Team Lead/PCP or Care Team (as the instructions may contain information necessary for the PCP or Care Team to follow up with the patient before the discharge summary is available). Upon discharge, the discharge summary is prepared within the Hospital EHR system. The attending physician of record (APoR) reviews the discharge summary and, once he has approved it, the discharge summary is sent to the Care Team Lead/PCP. The summary may arrive in the Care Team Lead/PCP’s EHR system even before the patient has left the hospital. A copy of the message may be retained in the hospital EHR per the hospital’s policies and workflow rules. [Same comment as above, information overload – PCP may want notification of transfer, but may not want this detail until PCP and care team are again responsible for the patient’s care]

NOTE: The discharge instructions described above are also part of the discharge summary. If the discharge summary is ready at the time of physical discharge, it is the only document necessary to be sent to the Care Team Lead/PCP or patient's care team.

A copy of the discharge summary/instructions may also be sent to the patient’s PHR.

Audit logs of the exchange are retained according to the hospital's, PCP's, and any intermediary's policies, procedures, and agreements.


 * Setting 7: Rehabilitation Facility (from Complex Series of Care Transitions user story)**

Activity The hospital discharge summary/instructions are received in the Rehab facility's EHR system. When the patient arrives he is admitted and the EHR updated. The EHR system provides the patient information for review by the lead nurse, lead therapist and physician that will be caring for the patient. Once reviewed and approved by the clinicians in accordance with the facility’s policies, protocols and workflows, the information is available to all of the rehab staff that will be caring for the patient [? This information will definitely shape the care plan but admission H&P and orders are still required by law; therefore would anticipate using this information to ensure reconciliation activities for example]. The patient’s Care Team Lead/PCP receives a summary of the recommended care plan. The patient’s PHR receives copies of rehab case review notes and ADL evaluations so that the DPOA-HC can actively monitor the patient’s progress and assist in planning patient’s discharge destination post-rehab.

Upon completion of the rehabilitation, the patient is discharged to home/Care Team Lead/PCP (see Hospital Discharge user story). [Now the PCP would want the complete information]


 * Setting 8: Outside Care Team Specialist’s office (from Hospital Discharge and Closed Loop Referral user stories)**

Activity: An orthopedist was the referred specialist from Care Team Lead/PCP (setting 4) as well as the patient's surgeon (setting 6). The consultation request clinical summary is processed according to the specific context of the referral. In accordance with practice policies and workflow the specialist reviews the document and orders any additional tests to be performed for the patient prior to the office visit. Discrete data elements from within the summary may be promoted to the specialist’s EHR system.

When the patient arrives at the specialist’s office he is registered in accordance with practice policies and workflow. The specialist documents the encounter in the EHR system and prepares the consultation summary for the Care Team Lead/PCP. Once the consultation summary is prepared, it is addressed and sent to the Care Team Lead/PCP’s EHR system. A copy of the message is retained in the specialist’s EHR system.

The consult summary may also be sent to the patient's PHR system.


 * Setting 1(b): Care Team Lead/PCP’s or Patient's Care Team office (from all user stories)**

Six months later, The patient visits Care Team Lead/PCP for a regular visit. Care Team Lead/PCP is able to access the various clinical summaries, consult summaries, discharge summaries and discharge instructions. [I would hope that the PCP and care team would have had an encounter with the patient within the week following the discharge to review and update the care plan] Care Team Lead/PCP notes that there is no record of encounter with the optician. An exception report had also been created by the Case Manager/Navigator/Nurse and alerted Care Team Lead/PCP after 1 months post the expected completion date. Care Team Lead/PCP counsels the patient on the risks of retinopathy and advises him to visit the optician for a check as soon as possible.

Care Team Lead/PCP may send the clinical summary and care plan to the patient's PHR system.

6.0 Data Fields for Care Plans that Create "Interoperability"

 * Discussion of Interoperability in Care Plans**

1. What would it mean for the parts of the care plan to be interoperable? a. Common identifier scheme to determine contributors b. Versioning of care plans or how one care plan component connects to another (versioning, links to contributing documents) c. Publish and subscribe model - Similar to a wiki where multiple people contribute and react to the care plan changes - changes and an interactive process where others confirm change or a an amount of time elapses. d. Underlying strong auditing process that allows movement back to see points in time and contributions e. Specified standards for the data elements that are exchanged. i. data elements for clinical sharing (ToC, CIM, Standards Analysis is defining) ii. data elements which cause interoperability iii. PCAST type data like meta-data - who it came from, versioning of terminology, digital signatures, etc. - trust creating data f. Interoperability not only between EHRs but also EHR to PHR

2. A<span style="font-family: Calibri,sans-serif; font-size: 15px; line-height: 22px;"> baseline roadmap defines the necessary foundation and structured document criteria with data elements for Care Planning. In addition a roadmap is identified which realizes interoperability resulting in the ability to update and maintain a longitudinal, forward looking care plan. The following information describes the roadmap.

**Foundation**:


 * Care plan is a dynamic document.
 * Pertinent means the sending physician's discretion
 * Core is included throughout the care plan and the data exchanged


 * Roadmap to Interoperability:** Includes the progress toward a care plan document as described in section 2.0, the key data elements to be exchanged to create interoperability, and a software expectations.

Medication Allergies and Adverse Reaction Active Problem List Reconciled Medications || Versioning (such as care plan id), date/time, creator(s)/editor(s)etc. ||  ||   || Care plan data elements in B plus: || (exchange "packet" includes all three sections described) |||||||||| ** 1. Provenance and Other Header MetaData aligned with PCAST - see Meta Power Team ** (e.g., who created, who it came from, version of terminology, digital signatures, verification that it hasn't been changed, last reviewed, auditing support) || Medication Allergies and Adverse Reaction Active Problem List Reconciled Medications || Pertinent Results, Pertinent History, Pertinent Review of Systems (ROS), Pertinent Physical Exam Findings, Procedures, Non invasive intervention (such as education, physical therapy, etc.), Recommendations, Pending Tests and Procedures, Patient Acceptance and Understanding || Pertinent Results, Pertinent History, Pertinent Review of Systems (ROS), Pertinent Physical Exam Findings, Reasons for Referral, Pending Tests and Procedures, Patient Acceptance and Understanding, Pertinent part of care plan || PCP to Patient: Terms translated by the edge (PHR) system. Pertinent sections for self management are sent to the PHR (e.g., core plus, future interventions, education, goals). ||  ||
 * |||||||| ** Stages ** ||  ||
 * ** Roadmap Dimensions ** || ** A ** |||||| ** B ** || ** C ** ||
 * ** Care Plan Document ** ||= ** A. "Core" Elements ** ||||||= ** B.Care plan data elements ** ||= ** C. Additional care plan data elements ** ||
 * ** (Data Sections / Elements in Data Dictionary of a Care Plan) ** || Demographics (communication preference - Jim Hansen will provide)
 * ** (Data Sections / Elements in Data Dictionary of a Care Plan) ** || Demographics (communication preference - Jim Hansen will provide)
 * ||  || Goals, Orders and Interventions (Intent and promise status of the order - Pending, Active, Completed}, Patient (designee's) Agreement, Mental Status ||   ||   || Patient instructions/education, Social Situation (such as employment, ability to care for self, etc.), Health literacy ||
 * = ** Data Exchanged **
 * = ** Data Exchanged **
 * = ** Data Exchanged **
 * = ** Data Exchanged **
 * |||||| ** 2. Identifiers - provider id, patient id, care plan id, version, date/time, problem id/problem thread, etc. ** ||  ||   ||
 * |||||| ** 3. Clinical summary content exchanged - interest in including Nursing elements ** ||  ||   ||
 * ||= ** A. ToC of "Core" Elements ** ||= ** B. Data Elements to Update and Maintain Care Plan Sent to PCP ** ||= ** B. Data Elements Required to Specialist ** ||= ** B. Data Elements to Patient ** ||  ||
 * || Demographics
 * || Demographics
 * ||  ||   ||   || Specialist to Patient: Terms translated by the edge (PHR) system for instructions specific to the care provided by the specialist and informed consent ||   ||


 * Software Exchanges:**
 * EHR to EHR Exchange
 * EHR to PHR Exchange


 * Software Services:**
 * Metrics around care planning
 * Clinical Decision Support (CDS) around care planning, including health literacy aware "translation" for the purpose of care planning

Finished.

include component="page" wikiName="siframework" page="space.template.inc_contentleft_end"