Jeanine Davis discusses the importance of personalizing care plans. While care plans are often standardized, personalizing them by including a member's individual needs, goals, and circumstances leads to better outcomes. Davis provides an example of how to take a standardized asthma care plan and modify it slightly to make it more meaningful for a specific member. The key is focusing goals and interventions on what really matters to the member by learning their values, priorities, and barriers through discussion. This engagement helps the member feel invested in the care plan and more likely to achieve their health goals.

1. PERSONALIZING
CARE PLANS
Jeanine Davis, RN, Clinical Liaison
A G U I D E T O

2. Care plans are either the bane of a care manager’s day or
an invaluable tool to help focus efforts. Whatever end of the
spectrum you fall on, love them or despise them,
individualized care plans are a required component of many
regulatory agencies. Knowing care plans are required
doesn’t help move the needle towards the “love” side of the
equation. What would be helpful is an explanation, in simple
terms, of why personalizing a care plan makes a difference,
peppered with some practical advice on how to make it
easier to personalize a standardized care plan.

3. LET'S START WITH THE RATIONAL
“Why would you want to personalize a
care plan in the first place?” If you and
your member don’t know why you are
creating an individualized care plan, the
“how to” doesn’t really matter. The
exercise of creating a care plan shouldn’t
be a “check the box” chore. In addition to
being a requirement, a care plan should be
tailored to the member’s specific needs
and diagnosis, as well as being utilized as
a guide, teaching tool, or road map for
continuity of care activities. Sounds great,
right? Sure, but so far, this is just a
reiteration of the fundamentals. Let’s get
to “why” it is important to personalize a
care plan.

4. GOALS
It all comes down to the goals. Goals need to be meaningful, not to the
care manager, but to the member. If the member doesn’t think the goal in
their care plan is important, they are not going to be compliant or
achieve their goal. So, how do you determine what is most important to
the individual? You need to start by asking the member. While that
sounds simple enough, there are countless facets in this equation.
Everyone has a unique story or circumstance, and these factor into a
person’s values, motivators, principles, barriers and resources. All the
stuff that makes an individual unique should be considered and included.
If we start the conversation from the perspective that the member is the
expert in knowing what their personal goals and priorities are, then we
can start to connect health care goals to personal goals..

5. EXPECTATIONS, TARGETS,
INTERVANTIONS
Next, we need to help the member sustain their motivation
by setting clear expectations, targets, and interventions
in support of the goal. Straight forward enough, however,
all the unique factors that are included in a person’s
values, motivators, principles, barriers, and resources
need to be included when formulating targets and
interventions. Also, do a reality check. Are the targets
and interventions reasonable? Are they realistic and
achievable for this person? Discuss them with the member
and ensure that he/she understands what the targets are.
You want the member to be engaged and excited enough
with the process to track and monitor their own progress
towards the goal.

6. OUTCOMES
We now have personalized goals that
motivate the member. Let’s loop back to
the “why do you want to personalize a
care plan?” In a word, “outcomes”.
Outcomes are how we measure the
member and the care team’s success.
Simply put, a personalized care plan that is
meaningful to the member will result in
better outcomes. A goal that means
something to the member will keep that
person engaged throughout the process
because they can easily connect what is
important to them to the health care
intervention in their care plan.

7. EVIDENCE-BASED STANDARDIZED
CARE PLANS
Now that we understand the “why”, we move to the
“how”. We are all very busy and want to work smarter
rather than harder, so let’s not reinvent the wheel.
Start with utilizing those wonderful evidence-based
standardized care plans and turn them into something
that a member can relate to. When you personalize a
standardized care plan, you want to keep in mind that
there is a balancing act between the evidence-based
practices of the standard care plan and the member’s
personal experience, individual needs, and
perspective.
If you haven’t done so already, go back to the member
and glean a few more details about them directly. Ask
what is important to that person and what their
personal goals are. Once you have obtained this, start
thinking about how to tie the two parts together,
namely, their personal goals to their health care goals.
We are still looking for some quick and easy, practical
tips on “how” to utilize a standardized care plan as the
base for an individualized care plan.

8. AN EXAMPLE OF AN
INDIVIDUALIZED CARE PLAN
Still looking for some quick and easy tips on “how” to use a
standardized care plan as the foundation for an individualized
care plan? The following example will illustrate this. This is one
problem pulled from the TCS Asthma Standardized Care Plan
Tool.

9. THE PROBLEM
Exercise intolerance due
to Asthma symptoms.
Member will maintain
appropriate activity
level.
THE GOAL

10. THE
INTERVENTIONS
Assess current activity level,
exercise tolerance, and symptoms.
Assess medication regimen and
treatment plan.
Instruct on medication regimen,
treatment plan, and symptoms to
report.
Refer to provider re: need for
inhaler or other medications prior
to exercise.
Member's activity or
exercise is not limited by
Asthma symptoms.
THE OUTCOME

11. 01
ALTHOUGH..
Although this portion of a care plan is nice, it is
not as individualized as it could be. The member
isn’t likely to relate to the goal, making it
unlikely that the outcome will be achieved. Here
is the key-- you don’t need to make huge
sweeping changes. Just making small changes
will make huge differences toward creating an
individualized plan. Start with taking those
personal details you just captured from the
member and insert them into the care plan.
Once you insert a couple of personal details
about the member, you change a standardized
care plan into a personalized care plan. Where
do these personal details go? Continuing with
the example above, modify a few things, like:

12. THE PROBLEM
“Exercise Intolerance
Due to Asthma
Symptoms.” This doesn’t
need to change! The
member does have this
problem and it does
need to be addressed.
This does need to change for this person.
The original goal is vague and most likely
doesn’t mean much to your member.
However, this is where a few small
changes to the words can make a huge
difference by making the goal
individualized and meaningful to your
member. For instance, the new goal could
be “Member will be able to resume daily
walks to the corner store.” Now your
member has a direct connection. Now the
interventions that are set standards of
care make sense for this person. Now you
have some “buy in” and willingness to
participate in assessments, medication
adherence, and the rest of the
interventions which will make it more likely
that the desired outcome will be achieved.
THE GOAL

13. THE
INTERVENTIONS
All are still relevant for
this problem and goal.
They don’t need to be
modified for your
member.
This will need to be tailored
to match the member’s
personal goal of being able
to walk to the corner store
every day. The new outcome
could be “Member will be
able to walk to the corner
store.”
THE OUTCOME

14. 01
IN CONCLUSION
By creating goals and outcomes that prioritize what is most
important to the member you avoid conflict or worse the
dreaded non-compliance to the care plan. Utilizing standardized
care plans is a typical practice across the industry and most
agree that standardized care helps to promote quality,
consistency and contain cost, however be aware of the pit falls
to utilizing standardized care plans. The chief risk is that care
managers are busy and sometimes overlook personalizing the
care plan. Unfortunately, this oversight will lead to a failure to
meet the NCQA standard of “Develop personalized, patient-
centered care plans”
The bottom line-- a care plan needs to work for an entire health
care team, including the member, as a guide to getting to a
goal. Knowing what your member’s obstacles, preferences,
values, and needs are can help develop how the goals are
formulated and how the member understands the connection
between their personal goals and health care goals. Identifying
and understanding why each goal is important specifically to
that person is crucial in motivating members toward and
achieving their goals. Personalizing the care plan to the member
will go a long way in ensuring achievement of those goals.

15. 08
3/30/2017, Can You and Your Patients Have It All? Why You Should Personalize and Standardize Care Plans. Healthwise Care
Coordination Team, https://www.healthwise.org/about/blog/march-2017/can-you-and-your-patients-have-it-all-why-you-sho.aspx
01/19/2015, Standardization vs. Personalization: Can Healthcare Do Both? HIT Consultant by James Dias.
http://hitconsultant.net/2015/01/19/standardization-vs-personalization-can-healthcare-do-both/
11:13 AM on March 6, 2017 The Bridge; Why 'standardized' and 'personalized' care are two sides of the same coin. by Shobhita
Narain. https://www.advisory.com/research/health-care-industry-committee/the-bridge/2017/03/standardization-and-personalization
Quality and Safety Education for Nurses (QSEN) article originally printed in Nursing Outlook Special Issue: Quality and Safety
Education. http://qsen.org/competencies/pre-licensure-ksas/
NCQA Case Management Accreditation©2012 National Committee for Quality Assurance. Setting Goals with People with Complex
Needs: A Collaborative Approach HEDIS & Quality Measurement » Research » Setting Goals with Vulnerable People HEDIS &
Quality Measurement » Research » Setting Goals with Vulnerable People. http://www.ncqa.org/hedis-quality-
measurement/research/setting-goals-with-vulnerable-people.
And
http://www.ncqa.org/Portals/0/Programs/Accreditation/Case%20Management/NCQA%20Case%20Management%20Accreditation_9.
25.13.pdf?ver=2013-09-25-154104-000
TCS Asthma Standardized Care Plan Tool
References

16. VISIT US AT!
www.tcshealthcare.com/clinical-corner
F O R M O R E