ToC+-+Care+Planning+Sub-Workgroup+Meeting+Summary

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 * Date:** 06/14/11
 * Name:** Transition of Care (ToC) Care Planning Sub-Workgroup Session Face-to-Face Meeting Agenda

__Panelist Attendees:__ Amy Berk, Arien Malec, Holly Miller, Russell Leftwich
 * Attendees:**

__Sub-Workgroup Attendees:__ Face to Face Participants (in person and web-ex)


 * Action Items:**
 * **Action Item** || **Next Steps / Status** || **Lead** || **Contributors** || **Due Date** ||
 * Incorporate Susan Campbell’s additions to User Story 3 || In Progress || Susan Campbell || Support Leads ||  ||
 * Revisit Parking Lot Items || In Progress ||  ||   ||   ||
 * Make formatting adjustments and post revised documents to the wiki || In Progress ||  ||   ||   ||


 * Notes from Discussion:**
 * __Overview of Care Plan Workgroup:__**
 * The members of this group have been working with the concept that somewhere there is a master care plan that is necessary for the overall quality of care.
 * The primary care physician (PCP) holds the authority over the master care plan for the patient (unless that physician has abdicated responsibility to a specialist in a complicated case).
 * Although the PCP maintains the overall responsibility, there is an entire care team involved. There are areas of the care plan that need to be updated and monitored such as:
 * Hospital discharge instructions.
 * Recommendations that the specialist makes
 * Those will update the master care plan to encompass all of that
 * Patient self management needs to be interoperable and this group is working to identify elements that need to be transmitted from an EHR to the patient’s PHR.
 * The care plan is a forward looking document. It’s important to remember that the contents of this document will be different than a summary.
 * The CIM group is working with a set of core data elements that will be transmitted with each transition of care which are listed below:
 * Problem list, reconciled medications, allergy intolerance list, patient demographics
 * An important assumption is that the care plan and the order are separate processes.
 * An order is a clinical authorization to do something where as a care plan in a transition of care process which expresses a roadmap.
 * Another important assumption as part of the process is that there is intra-institution exchange of information rather than an inter-organization exchange.
 * A Care Team consists of many roles (PCP, Embedded care manager, nurse, etc) and the scope of the care depends on the complexity of the patient centered medical home.


 * __Care Plan Spreadsheet and Word Document Discussion:__**
 * The Care Plan itself is a Progressive model, meaning that all of the parts build on each other.
 * A. Core Data Elements
 * These core elements are an essential part for any transition of care environment. You would **__always__** need each one of these data elements at a minimum.
 * In general these are currently documented in state EHRs as discrete data.
 * B. Care plan data elements
 * These care plan data elements are maintained by care plan team.
 * Would include goals, all orders and interventions (the plan), order status (pending, active, completed), Agreement, Mental Status (National Transition of Care Collaborative as one of the recommended ‘ideal data elements for transition of care’).
 * C. Additional Care plan elements
 * These additional elements are often not available in EHRs and even if they are, there is no data model to incorporate them.
 * Some examples of these elements are, Patient instructions/education, Social Situation (such as employment, ability to care for self, etc.), Health literacy
 * One participant suggested changing the term, “Social Situation” to read, “Social determinants of health”


 * The rest of this discussion revolved around making edits and changes to both the spreadsheet and the word document which were both outputs of the work from the Care Planning sub-workgroup. The next points will review some key decisions and discussion points that occurred during this part of the meeting. To view the updated spreadsheet and word document, please reference the care planning sub-workgroup page on the Wiki.


 * Within the care plan elements, metadata is comprehensive to include date and time stamps
 * There was a large discussion about where to add “home care” as another point under order or follow up appointments. The group decided to leave it under follow up appointments because it is a follow up service.
 * Another discussion that was resulted in a parking lot item was around the idea of, where the findings go when there are things that need to be reported back to the medical home?
 * This was in relation to discussions about medication, dosages, etc. This type of information would be critical for the care plan to be informed by that information and ideally as these systems become interoperable the pharmacy system would be able to report this
 * Ancillary Team Member to PCP (Pharmacist in some systems is included on the Care Team)
 * Another discussion revolved around the idea of scales that are used to measure goals within the care plan. A participant mentioned that some medical home protocols have assessments build in to measure against goals. Whether or not they meet goals they decide to go around another round of care planning and then measure again and therefore we should be considering them as part of the care plan.
 * There was some back and forth about where to place the scales under “Assessment” as an assessment is in many cases a decision point.
 * It was suggested to put this as a parking lot item and search for a DM with expertise to understand this idea better.
 * The spreadsheet walked the group through the idea of the data moving throughout members of the care team.
 * In all cases all core elements will always move with any transition but for the group B elements, the data will move at the choice of the Clinician.
 * The clinician creating message to PCP will have to select a “pertinent” group of results that will then go with a transition of care.
 * The term “pertinent history” included “Behavioral History” which the group felt like needed a proper definition for. The group decided to put this as another parking lot item and felt like they should do more research on appropriate terms and examples to go along with this idea of “Behavioral History”
 * A participant suggested that Britain has been doing a lot of analysis on this topic and we might be able to find some valuable information there.
 * The group also decided to add the phrase, “Patient Understanding and Agreement” as another Parking lot item to decide on a better word / phrase to say this.
 * The idea of a PCP handing over the responsibility of a patient’s care plan in a complicated case was another idea that was talked about in detail.
 * The group decided to add a clause within the document that says, “*situations may occur where there is a shared medical home responsibilities and it may be dynamic; requiring communication between providers” to address this issue.
 * In response to this discussion another participant asked about the legal associations with the transfer of care from a PCP to specialist or vice versa.
 * To consult someone is one thing but to have another physician writing prescriptions for a certain patient – what are the legal parameters behind this?
 * This was designated as another parking lot item that could be discussed in more length at a different time as legal dimensions are out of the scope of this workgroup.
 * Susan Campbell had completed some work on User Story 3 that was not reflected in these documents.
 * The Support Leads and Wiki administrators will work with Susan to figure out where this content has gone.
 * __Wrap Up:__**
 * The group in the room achieved formal consensus, determining that the Care Planning Sub-Workgroup achieved the goal of developing a comprehensive care plan and move forward in the time frame that was anticipated.


 * __Parking Lot Items:__**
 * 1) More research on the term, “Behavioral History”
 * 2) Find a better way to phrase, “Patient Understanding and Agreement”
 * 3) Research more the legal associations with the transfer of care from a PCP to specialist or vice versa.
 * 4) Analyze the Pharmacy to PCP interaction and where the findings go when there are things that need to be reported back to the medical home? (Pharmacy to PCP)
 * 5) Search for a DM with expertise to ascertain where the idea of scales to measure against goals which determine changes to the care plan can fit within the document.

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