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Care planning Getting Better Together

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CARE PLANNING
Getting Better Together.
Dr. Syed Mohammad Tayib

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Objectives
• Best practice
• Quality and Patient safety
• Person Centered Care
Rationale for improvement
• SMART Goals
• G...

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Defining Care Planning
Building a Care Plan: Care plans include,
but are not limitedto,the following:
Prioritized goals fo...

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Care planning Getting Better Together

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A PPT on care planning integrated with concepts of people centered care.

A modified approach to Care planning where provider, client and family partnership leads the way in deriving goals and measurable elements for improvement that are most important to clients and their families.

Partnership in care planning instills rightly a greater sense of investment and ownership among client and their families which promotes better compliance, and eventually results in better clinical outcomes.

A PPT on care planning integrated with concepts of people centered care.

A modified approach to Care planning where provider, client and family partnership leads the way in deriving goals and measurable elements for improvement that are most important to clients and their families.

Partnership in care planning instills rightly a greater sense of investment and ownership among client and their families which promotes better compliance, and eventually results in better clinical outcomes.

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Care planning Getting Better Together

  1. 1. CARE PLANNING Getting Better Together. Dr. Syed Mohammad Tayib
  2. 2. Objectives • Best practice • Quality and Patient safety • Person Centered Care Rationale for improvement • SMART Goals • Goals concept • Care Plan Parameters Settinggoals and measuring them Modified Pare Plan IntegratedCare Planning
  3. 3. Defining Care Planning Building a Care Plan: Care plans include, but are not limitedto,the following: Prioritized goals for a patient’s healthstatus Established timeframes for reevaluation Resources that might benefit the patient,includinga recommendationas to the appropriate level ofcare Planningfor continuity of care, includingassistance making the transitionfrom one care settingto another Collaborativeapproaches to health, includingfamily participation Guiding Principle A care plan should enhance the patient’s treatment plan by providinga list of identified health conditions or problems with a correspondingprioritized list of interventions to meet the patient’s goals. [2]
  4. 4. Best Practice • Quality & Patient Safety • Safety and efficiency is achieved through effectivecommunication, collaborationand standardized Processes to ensure that the planning, coordination, implementation and of care supports and responds to each patient’s unique needs and goals
  5. 5. Best Practice • PersonCenteredCare • incorporating person-centered care planning principles • Person-centered care begins with the individual’s goals and respects and addresses their preferences and needs • improve their health and social outcomes by developing and implementing individualizedcare plans based on the goals that are most important to the individual. • Ownership - engagementin setting goals has been demonstrated to affect not only their participation in and adherence to treatment, but their health outcomes and quality of life
  6. 6. Setting Goals and Measuring Them • SMART Goals: • Specific: The goal should be specific to the patient’s situation and focused on one desired outcome. • Measurable: The goal must be a measurable, evidence-based outcome. • Achievable: The goal must be reasonably achievable based on patient’s condition • Relevant:The goal mustbe individualized to the patient, based on stated needs, desires, and assessment findings • Time Specific:Goals need to include a target date that is achievable.
  7. 7. Setting Goals and Measuring Them • Goal Concepts: • Problem statementwith an action plan that is measurable, obtainable,and important to the patient. • What is highest priority for the patient? • Identify what the patient wants to happen/do, when to have it completed, and how you will as the PCP/MRP know that it is done. • Barrier(s): Any factor that can limit the patientfrom achieving the goals set forth in the care plan (i.e., lack of transportation, financialissues, social issues, lack of knowledge. • Intervention(s): The steps that need to be taken to assist the patient to reach the goal(s): • Interventionmust be prioritized and customized for each patientto resolve the issue/problem that will have the highest impact on patient’shealth status • Continuousreprioritizationof the care/interventionsfor the patient must occur based on the most recent interactionsand new information from clinician. • Evaluation: Ongoing review and revision of the care plan until goals or met. Thismay include developmentof new goals.
  8. 8. Setting Goals and Measuring Them Care Plan Parameters 1. Problem List 2. Goals a) In patient’s own words (family if involved is also included) b) Goals defined in clinical terms based on the problem list. Prioritized based on clinical condition and patient buy in. i. Measurable Elements for improvement defined 3. Identify Barriers to achieving goals 4. Establish intervention 5. Instructionsand follow up
  9. 9. Modified Care Planning • Goals are reassessed and modified in conjunction with the patient • Information captured will be in the same format as the care plan
  10. 10. IntegratedCare Planning When multiple clinicians are involved in the care of the patient Care plans of other clinicians are derived from that of the physician’s The care plans are Ideally integrated and are visible in the same page/ sheet. All measurable elements of improvement link to the goals of patients
  11. 11. References 1. PatientCentered Primary Care: Care Plan Development;Anthem– Blue Cross. [web link: https://www22.anthem.com/providertoolkit/ss3_updatedcareplanplaybook_abcbs.pdf] 2. Goals to Care: How to keep the person in “person-centered”;The National Committee for Quality Assurance [web link: https://www.ncqa.org/wp- content/uploads/2018/07/20180531_Report_Goals_to_Care_Spotlight_.pdf] 3. Writing Good Care Plans: A Good Practice Guide; Oxleas, NHS, Care Coordination Association. [ weblink: http://oxleas.nhs.uk/site-media/cms- downloads/Writing_Good_Care_Plans_Oxleas.pdf ] 4. Complex Care Management Toolkit; California Quality Collaborative, California Healthcare Foundation. [web link: http://www.calquality.org/storage/documents/cqc_complexcaremanagement_toolkit_final.pdf ]

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