SlideShare a Scribd company logo
CARE PLANNING
Getting Better Together.
Dr. Syed Mohammad Tayib
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
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]
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
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
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.
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.
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
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
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
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
]

More Related Content

What's hot

Cost effectiveness and cost efficiency
Cost effectiveness and cost efficiencyCost effectiveness and cost efficiency
Cost effectiveness and cost efficiency
Nursing Hi Nursing
 
NCPT for EAL
NCPT for EALNCPT for EAL
NCPT for EAL
KellyGCDET
 
NFMNT Chapter 17 Participate in Regulatory Surveys
NFMNT Chapter 17 Participate in Regulatory SurveysNFMNT Chapter 17 Participate in Regulatory Surveys
NFMNT Chapter 17 Participate in Regulatory Surveys
KellyGCDET
 
MiPCT Webinar 2/5/2014
 MiPCT Webinar 2/5/2014 MiPCT Webinar 2/5/2014
MiPCT Webinar 2/5/2014
mednetone
 
Preventing Hospital Readmissions - Home Instead Senior Care
Preventing Hospital Readmissions - Home Instead Senior CarePreventing Hospital Readmissions - Home Instead Senior Care
Preventing Hospital Readmissions - Home Instead Senior Care
Stephanie Derry
 
Care coordination training
Care coordination trainingCare coordination training
Care coordination training
Aesculapius Healthcare Consultants
 
Standards and audit for quality assurance
Standards and audit for quality assuranceStandards and audit for quality assurance
Standards and audit for quality assurance
rohini154
 
NFMNT Chapter 9 Document Nutritional Information in the Medical Record
NFMNT Chapter 9 Document Nutritional Information in the Medical RecordNFMNT Chapter 9 Document Nutritional Information in the Medical Record
NFMNT Chapter 9 Document Nutritional Information in the Medical Record
KellyGCDET
 
Lesson 5
Lesson 5Lesson 5
The outcomes & effectiveness of revalidation in New Zealand for non-certified...
The outcomes & effectiveness of revalidation in New Zealand for non-certified...The outcomes & effectiveness of revalidation in New Zealand for non-certified...
The outcomes & effectiveness of revalidation in New Zealand for non-certified...
IAMRAreval2015
 
Using ExamSoft Codings to Identify Gaps and Strengths with the NCLEX-RN Test ...
Using ExamSoft Codings to Identify Gaps and Strengths with the NCLEX-RN Test ...Using ExamSoft Codings to Identify Gaps and Strengths with the NCLEX-RN Test ...
Using ExamSoft Codings to Identify Gaps and Strengths with the NCLEX-RN Test ...
ExamSoft
 
Ppt of nursing audit
Ppt of nursing auditPpt of nursing audit
Ppt of nursing audit
AkanshaJohn1
 
Clinical pathways
Clinical pathwaysClinical pathways
Clinical pathways
Ihsan ullah khamoosh
 
NFMNT Chapter 4 Manage Food Allergies, Complementary, and Alternative Medicine
NFMNT Chapter 4 Manage Food Allergies, Complementary, and Alternative MedicineNFMNT Chapter 4 Manage Food Allergies, Complementary, and Alternative Medicine
NFMNT Chapter 4 Manage Food Allergies, Complementary, and Alternative Medicine
KellyGCDET
 
NFMNT Chapter 13 Apply Standard Nutrition Care
NFMNT Chapter 13 Apply Standard Nutrition CareNFMNT Chapter 13 Apply Standard Nutrition Care
NFMNT Chapter 13 Apply Standard Nutrition Care
KellyGCDET
 
Academy Health-Annual Research Meeting Presentation
Academy Health-Annual Research Meeting PresentationAcademy Health-Annual Research Meeting Presentation
Academy Health-Annual Research Meeting Presentation
scherala
 
Code of Ethics for the Dietetic Professional
Code of Ethics for the Dietetic ProfessionalCode of Ethics for the Dietetic Professional
Code of Ethics for the Dietetic Professional
KellyGCDET
 
CLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINES
CLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINESCLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINES
CLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINES
Mary Ann Adiong
 
Saving Lives by Design: the role of user experience in adoption and adherence...
Saving Lives by Design: the role of user experience in adoption and adherence...Saving Lives by Design: the role of user experience in adoption and adherence...
Saving Lives by Design: the role of user experience in adoption and adherence...
3GDR
 
Physical Therapy Assistant Jennifer Hernandez
Physical Therapy Assistant   Jennifer HernandezPhysical Therapy Assistant   Jennifer Hernandez
Physical Therapy Assistant Jennifer Hernandez
Stephanie Sawyer, M.S.
 

What's hot (20)

Cost effectiveness and cost efficiency
Cost effectiveness and cost efficiencyCost effectiveness and cost efficiency
Cost effectiveness and cost efficiency
 
NCPT for EAL
NCPT for EALNCPT for EAL
NCPT for EAL
 
NFMNT Chapter 17 Participate in Regulatory Surveys
NFMNT Chapter 17 Participate in Regulatory SurveysNFMNT Chapter 17 Participate in Regulatory Surveys
NFMNT Chapter 17 Participate in Regulatory Surveys
 
MiPCT Webinar 2/5/2014
 MiPCT Webinar 2/5/2014 MiPCT Webinar 2/5/2014
MiPCT Webinar 2/5/2014
 
Preventing Hospital Readmissions - Home Instead Senior Care
Preventing Hospital Readmissions - Home Instead Senior CarePreventing Hospital Readmissions - Home Instead Senior Care
Preventing Hospital Readmissions - Home Instead Senior Care
 
Care coordination training
Care coordination trainingCare coordination training
Care coordination training
 
Standards and audit for quality assurance
Standards and audit for quality assuranceStandards and audit for quality assurance
Standards and audit for quality assurance
 
NFMNT Chapter 9 Document Nutritional Information in the Medical Record
NFMNT Chapter 9 Document Nutritional Information in the Medical RecordNFMNT Chapter 9 Document Nutritional Information in the Medical Record
NFMNT Chapter 9 Document Nutritional Information in the Medical Record
 
Lesson 5
Lesson 5Lesson 5
Lesson 5
 
The outcomes & effectiveness of revalidation in New Zealand for non-certified...
The outcomes & effectiveness of revalidation in New Zealand for non-certified...The outcomes & effectiveness of revalidation in New Zealand for non-certified...
The outcomes & effectiveness of revalidation in New Zealand for non-certified...
 
Using ExamSoft Codings to Identify Gaps and Strengths with the NCLEX-RN Test ...
Using ExamSoft Codings to Identify Gaps and Strengths with the NCLEX-RN Test ...Using ExamSoft Codings to Identify Gaps and Strengths with the NCLEX-RN Test ...
Using ExamSoft Codings to Identify Gaps and Strengths with the NCLEX-RN Test ...
 
Ppt of nursing audit
Ppt of nursing auditPpt of nursing audit
Ppt of nursing audit
 
Clinical pathways
Clinical pathwaysClinical pathways
Clinical pathways
 
NFMNT Chapter 4 Manage Food Allergies, Complementary, and Alternative Medicine
NFMNT Chapter 4 Manage Food Allergies, Complementary, and Alternative MedicineNFMNT Chapter 4 Manage Food Allergies, Complementary, and Alternative Medicine
NFMNT Chapter 4 Manage Food Allergies, Complementary, and Alternative Medicine
 
NFMNT Chapter 13 Apply Standard Nutrition Care
NFMNT Chapter 13 Apply Standard Nutrition CareNFMNT Chapter 13 Apply Standard Nutrition Care
NFMNT Chapter 13 Apply Standard Nutrition Care
 
Academy Health-Annual Research Meeting Presentation
Academy Health-Annual Research Meeting PresentationAcademy Health-Annual Research Meeting Presentation
Academy Health-Annual Research Meeting Presentation
 
Code of Ethics for the Dietetic Professional
Code of Ethics for the Dietetic ProfessionalCode of Ethics for the Dietetic Professional
Code of Ethics for the Dietetic Professional
 
CLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINES
CLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINESCLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINES
CLINICAL PATHWAY and CLINICAL PRACTICE GUIDELINES
 
Saving Lives by Design: the role of user experience in adoption and adherence...
Saving Lives by Design: the role of user experience in adoption and adherence...Saving Lives by Design: the role of user experience in adoption and adherence...
Saving Lives by Design: the role of user experience in adoption and adherence...
 
Physical Therapy Assistant Jennifer Hernandez
Physical Therapy Assistant   Jennifer HernandezPhysical Therapy Assistant   Jennifer Hernandez
Physical Therapy Assistant Jennifer Hernandez
 

Similar to Care planning Getting Better Together

Tx_Planning_for_SUD_v3.0.pdf
Tx_Planning_for_SUD_v3.0.pdfTx_Planning_for_SUD_v3.0.pdf
Tx_Planning_for_SUD_v3.0.pdf
AlejandraCastillo519579
 
Nursing Process Approach.pptx
Nursing Process Approach.pptxNursing Process Approach.pptx
Nursing Process Approach.pptx
SGRRIMHS
 
steps of nursing process, Planning
steps of nursing process, Planningsteps of nursing process, Planning
steps of nursing process, Planning
Arifa T N
 
Nursing process planning
Nursing process planningNursing process planning
Nursing process planning
Anuchithra Radhakrishnan
 
Planning.pptx
Planning.pptxPlanning.pptx
Planning.pptx
Nagamani Manjunath
 
NURSING CASE MANAGEMENT & CRITICAL PATHWAYS OF CARE.pptx
NURSING CASE MANAGEMENT & CRITICAL PATHWAYS OF CARE.pptxNURSING CASE MANAGEMENT & CRITICAL PATHWAYS OF CARE.pptx
NURSING CASE MANAGEMENT & CRITICAL PATHWAYS OF CARE.pptx
SushmaLath
 
Brochure-Training-web
Brochure-Training-webBrochure-Training-web
Brochure-Training-web
Linda Smith
 
Brochure-Training-web
Brochure-Training-webBrochure-Training-web
Brochure-Training-web
Adam Perlman
 
V.3. Nursing as a Science, Planning.pptx
V.3. Nursing as a Science, Planning.pptxV.3. Nursing as a Science, Planning.pptx
V.3. Nursing as a Science, Planning.pptx
JRRolfNeuqelet
 
nursing process . In nursing management.
nursing process . In nursing management.nursing process . In nursing management.
nursing process . In nursing management.
TulsiDhidhi1
 
How to Write a Nursing Care Plan.pdf
How to Write a Nursing Care Plan.pdfHow to Write a Nursing Care Plan.pdf
How to Write a Nursing Care Plan.pdf
LudacrissJaydenLomba
 
bec181231aed4c17d00b49d1809f4dc8.pdf
bec181231aed4c17d00b49d1809f4dc8.pdfbec181231aed4c17d00b49d1809f4dc8.pdf
bec181231aed4c17d00b49d1809f4dc8.pdf
LudacrissJaydenLomba
 
Health planning
Health planningHealth planning
Health planning
mlogaraj
 
Developing key performance_indicators
Developing key performance_indicatorsDeveloping key performance_indicators
Developing key performance_indicators
sssssana
 
Evaluation.pptx
Evaluation.pptxEvaluation.pptx
Evaluation.pptx
SGRRIMHS
 
FHP Lec.. The Planning the Nursing care..pptx
FHP Lec.. The Planning the Nursing care..pptxFHP Lec.. The Planning the Nursing care..pptx
FHP Lec.. The Planning the Nursing care..pptx
Rehmat18
 
Nursing process in mental health
Nursing process in mental healthNursing process in mental health
Nursing process in mental health
slideshareacount
 
Nursing Process.pptx
Nursing Process.pptxNursing Process.pptx
Nursing Process.pptx
AnmolPrashar5
 
Webinar: Health Care Innovation Awards Round Two - Measuring for Success and...
 Webinar: Health Care Innovation Awards Round Two - Measuring for Success and... Webinar: Health Care Innovation Awards Round Two - Measuring for Success and...
Webinar: Health Care Innovation Awards Round Two - Measuring for Success and...
Centers for Medicare & Medicaid Services (CMS)
 
health need assessment
health need assessmenthealth need assessment
health need assessment
NursakinahBohari
 

Similar to Care planning Getting Better Together (20)

Tx_Planning_for_SUD_v3.0.pdf
Tx_Planning_for_SUD_v3.0.pdfTx_Planning_for_SUD_v3.0.pdf
Tx_Planning_for_SUD_v3.0.pdf
 
Nursing Process Approach.pptx
Nursing Process Approach.pptxNursing Process Approach.pptx
Nursing Process Approach.pptx
 
steps of nursing process, Planning
steps of nursing process, Planningsteps of nursing process, Planning
steps of nursing process, Planning
 
Nursing process planning
Nursing process planningNursing process planning
Nursing process planning
 
Planning.pptx
Planning.pptxPlanning.pptx
Planning.pptx
 
NURSING CASE MANAGEMENT & CRITICAL PATHWAYS OF CARE.pptx
NURSING CASE MANAGEMENT & CRITICAL PATHWAYS OF CARE.pptxNURSING CASE MANAGEMENT & CRITICAL PATHWAYS OF CARE.pptx
NURSING CASE MANAGEMENT & CRITICAL PATHWAYS OF CARE.pptx
 
Brochure-Training-web
Brochure-Training-webBrochure-Training-web
Brochure-Training-web
 
Brochure-Training-web
Brochure-Training-webBrochure-Training-web
Brochure-Training-web
 
V.3. Nursing as a Science, Planning.pptx
V.3. Nursing as a Science, Planning.pptxV.3. Nursing as a Science, Planning.pptx
V.3. Nursing as a Science, Planning.pptx
 
nursing process . In nursing management.
nursing process . In nursing management.nursing process . In nursing management.
nursing process . In nursing management.
 
How to Write a Nursing Care Plan.pdf
How to Write a Nursing Care Plan.pdfHow to Write a Nursing Care Plan.pdf
How to Write a Nursing Care Plan.pdf
 
bec181231aed4c17d00b49d1809f4dc8.pdf
bec181231aed4c17d00b49d1809f4dc8.pdfbec181231aed4c17d00b49d1809f4dc8.pdf
bec181231aed4c17d00b49d1809f4dc8.pdf
 
Health planning
Health planningHealth planning
Health planning
 
Developing key performance_indicators
Developing key performance_indicatorsDeveloping key performance_indicators
Developing key performance_indicators
 
Evaluation.pptx
Evaluation.pptxEvaluation.pptx
Evaluation.pptx
 
FHP Lec.. The Planning the Nursing care..pptx
FHP Lec.. The Planning the Nursing care..pptxFHP Lec.. The Planning the Nursing care..pptx
FHP Lec.. The Planning the Nursing care..pptx
 
Nursing process in mental health
Nursing process in mental healthNursing process in mental health
Nursing process in mental health
 
Nursing Process.pptx
Nursing Process.pptxNursing Process.pptx
Nursing Process.pptx
 
Webinar: Health Care Innovation Awards Round Two - Measuring for Success and...
 Webinar: Health Care Innovation Awards Round Two - Measuring for Success and... Webinar: Health Care Innovation Awards Round Two - Measuring for Success and...
Webinar: Health Care Innovation Awards Round Two - Measuring for Success and...
 
health need assessment
health need assessmenthealth need assessment
health need assessment
 

Recently uploaded

NKTI Annual Report - Annual Report FY 2022
NKTI Annual Report - Annual Report FY 2022NKTI Annual Report - Annual Report FY 2022
NKTI Annual Report - Annual Report FY 2022
nktiacc3
 
Hypotension and role of physiotherapy in it
Hypotension and role of physiotherapy in itHypotension and role of physiotherapy in it
Hypotension and role of physiotherapy in it
Vishal kr Thakur
 
DRAFT Ventilator Rapid Reference version 2.4.pdf
DRAFT Ventilator Rapid Reference  version  2.4.pdfDRAFT Ventilator Rapid Reference  version  2.4.pdf
DRAFT Ventilator Rapid Reference version 2.4.pdf
Robert Cole
 
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
bkling
 
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...
The Lifesciences Magazine
 
Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...
Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...
Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...
nirahealhty
 
How Effective is Homeopathic Medicine for Anxiety and Stress Relief.pdf
How Effective is Homeopathic Medicine for Anxiety and Stress Relief.pdfHow Effective is Homeopathic Medicine for Anxiety and Stress Relief.pdf
How Effective is Homeopathic Medicine for Anxiety and Stress Relief.pdf
Dharma Homoeopathy
 
Letter to MREC - application to conduct study
Letter to MREC - application to conduct studyLetter to MREC - application to conduct study
Letter to MREC - application to conduct study
Azreen Aj
 
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...
rightmanforbloodline
 
Pediatric Emergency Care for Children | Apollo Hospital
Pediatric Emergency Care for Children | Apollo HospitalPediatric Emergency Care for Children | Apollo Hospital
Pediatric Emergency Care for Children | Apollo Hospital
Apollo 24/7 Adult & Paediatric Emergency Services
 
RECENT ADVANCES IN BREAST CANCER RADIOTHERAPY
RECENT ADVANCES IN BREAST CANCER RADIOTHERAPYRECENT ADVANCES IN BREAST CANCER RADIOTHERAPY
RECENT ADVANCES IN BREAST CANCER RADIOTHERAPY
Isha Jaiswal
 
Hypertension and it's role of physiotherapy in it.
Hypertension and it's role of physiotherapy in it.Hypertension and it's role of physiotherapy in it.
Hypertension and it's role of physiotherapy in it.
Vishal kr Thakur
 
Top Rated Massage Center In Ajman Chandrima Spa
Top Rated Massage Center In Ajman Chandrima SpaTop Rated Massage Center In Ajman Chandrima Spa
Top Rated Massage Center In Ajman Chandrima Spa
Chandrima Spa Ajman
 
Pneumothorax and role of Physiotherapy in it.
Pneumothorax and role of Physiotherapy in it.Pneumothorax and role of Physiotherapy in it.
Pneumothorax and role of Physiotherapy in it.
Vishal kr Thakur
 
INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)
INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)
INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)
blessyjannu21
 
Tips for Pet Care in winters How to take care of pets.
Tips for Pet Care in winters How to take care of pets.Tips for Pet Care in winters How to take care of pets.
Tips for Pet Care in winters How to take care of pets.
Dinesh Chauhan
 
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COMHUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
priyabhojwani1200
 
Empowering ACOs: Leveraging Quality Management Tools for MIPS and Beyond
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondEmpowering ACOs: Leveraging Quality Management Tools for MIPS and Beyond
Empowering ACOs: Leveraging Quality Management Tools for MIPS and Beyond
Health Catalyst
 
Dr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in Cardiology
Dr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in CardiologyDr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in Cardiology
Dr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in Cardiology
R3 Stem Cell
 
Anxiety, Trauma and Stressor Related Disorder.pptx
Anxiety, Trauma and Stressor Related Disorder.pptxAnxiety, Trauma and Stressor Related Disorder.pptx
Anxiety, Trauma and Stressor Related Disorder.pptx
Sagunlohala1
 

Recently uploaded (20)

NKTI Annual Report - Annual Report FY 2022
NKTI Annual Report - Annual Report FY 2022NKTI Annual Report - Annual Report FY 2022
NKTI Annual Report - Annual Report FY 2022
 
Hypotension and role of physiotherapy in it
Hypotension and role of physiotherapy in itHypotension and role of physiotherapy in it
Hypotension and role of physiotherapy in it
 
DRAFT Ventilator Rapid Reference version 2.4.pdf
DRAFT Ventilator Rapid Reference  version  2.4.pdfDRAFT Ventilator Rapid Reference  version  2.4.pdf
DRAFT Ventilator Rapid Reference version 2.4.pdf
 
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)
 
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...
 
Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...
Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...
Can coffee help me lose weight? Yes, 25,422 users in the USA use it for that ...
 
How Effective is Homeopathic Medicine for Anxiety and Stress Relief.pdf
How Effective is Homeopathic Medicine for Anxiety and Stress Relief.pdfHow Effective is Homeopathic Medicine for Anxiety and Stress Relief.pdf
How Effective is Homeopathic Medicine for Anxiety and Stress Relief.pdf
 
Letter to MREC - application to conduct study
Letter to MREC - application to conduct studyLetter to MREC - application to conduct study
Letter to MREC - application to conduct study
 
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...
 
Pediatric Emergency Care for Children | Apollo Hospital
Pediatric Emergency Care for Children | Apollo HospitalPediatric Emergency Care for Children | Apollo Hospital
Pediatric Emergency Care for Children | Apollo Hospital
 
RECENT ADVANCES IN BREAST CANCER RADIOTHERAPY
RECENT ADVANCES IN BREAST CANCER RADIOTHERAPYRECENT ADVANCES IN BREAST CANCER RADIOTHERAPY
RECENT ADVANCES IN BREAST CANCER RADIOTHERAPY
 
Hypertension and it's role of physiotherapy in it.
Hypertension and it's role of physiotherapy in it.Hypertension and it's role of physiotherapy in it.
Hypertension and it's role of physiotherapy in it.
 
Top Rated Massage Center In Ajman Chandrima Spa
Top Rated Massage Center In Ajman Chandrima SpaTop Rated Massage Center In Ajman Chandrima Spa
Top Rated Massage Center In Ajman Chandrima Spa
 
Pneumothorax and role of Physiotherapy in it.
Pneumothorax and role of Physiotherapy in it.Pneumothorax and role of Physiotherapy in it.
Pneumothorax and role of Physiotherapy in it.
 
INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)
INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)
INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)
 
Tips for Pet Care in winters How to take care of pets.
Tips for Pet Care in winters How to take care of pets.Tips for Pet Care in winters How to take care of pets.
Tips for Pet Care in winters How to take care of pets.
 
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COMHUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
HUMAN BRAIN.pptx.PRIYA BHOJWANI@GAMIL.COM
 
Empowering ACOs: Leveraging Quality Management Tools for MIPS and Beyond
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondEmpowering ACOs: Leveraging Quality Management Tools for MIPS and Beyond
Empowering ACOs: Leveraging Quality Management Tools for MIPS and Beyond
 
Dr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in Cardiology
Dr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in CardiologyDr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in Cardiology
Dr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in Cardiology
 
Anxiety, Trauma and Stressor Related Disorder.pptx
Anxiety, Trauma and Stressor Related Disorder.pptxAnxiety, Trauma and Stressor Related Disorder.pptx
Anxiety, Trauma and Stressor Related Disorder.pptx
 

Care planning Getting Better Together

  • 1. CARE PLANNING Getting Better Together. Dr. Syed Mohammad Tayib
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 ]