A dynamic, holistic, personalized care plan that follows an individual over their lifetime can help drive quality care and overall well being. In this ideal state, care plans can support a connected, collaborative and patient-centered experience. However, fragmentation, duplication, and lack of patient engagement can be some of the most pressing challenges in the world of care planning. In this blog, we’ll explore the world of connected care planning and how technology will play a role in its advancement.
- Characteristics of an effective care plan
Care planning is an essential piece of care coordination that can foster continuous improvement throughout a healthcare organization. An effective care plan:
- Organizes patient health and care activities and promotes seamless information exchange from outside sources across the clinical and personal care team
- Establishes focus to improve communication and clarity of the patient story across all members that interact with the patient with the aim to reduce duplicate documentation, enhance clinician efficiency, and improve overall care
- Enables the person to be an active participant in managing their healthcare to improve collaboration and communication with their care team
- Advances value-based care strategies around preventative care, collaborative decision-making, and managing the total cost of care
- The real-world impact of care planning A person-centric approach allows health systems to provide more competent and robust patient care.
- Technology's role in care planning Access to relevant health care data, engagement and coordination can all be enriched by technology. Supporting a longitudinal care planning model has several benefits for the patient, clinicians, and healthcare organizations such as:
- Provides a single plan accessible across all platforms, all venues of care, and all care team members to reduce fragmentation, reduce silos and improve clinician efficiency
- Incorporates the longitudinal and acute aspects of a patient's care journey into a single point of access
- Extends the care plan to the patient, enabling them to be more active participants in the management of their health and wellness
- Expands the ability for care team members to create, capture, facilitate and update different components of a patient's care plan to improve care coordination and care team connectivity further
For example, let’s say the patient, “Jen,” was born prematurely, so her parents and pediatrician worked together to develop a care plan to ensure Jen's healthcare needs were always met. As Jen transitioned from childhood into adolescence, her care team expanded to include an ENT, a gynecologist, and other added specialists as plan contributors. Even though Jen's data spanned multiple electronic health records from childhood into her adult years, all relevant reports were captured and made available to Jen and her care team.
When Jen turned 40, her gynecologist recommended she start getting annual mammograms. The radiologist's interpretation of her exam was included in Jen's care plan, allowing her gynecologist easy access to related goals and activities and current status even though the providers were at different health systems. If an unplanned event occurred and Jen was admitted to the hospital, data captured for this acute event related to her care plan was also documented in her records. In addition, long-term goals and activities were evaluated and paused as appropriate and then resumed when Jen's health issues were resolved.
Rather than being tethered to a single encounter, venue, or provider, a comprehensive technology solution can help and connect various methods of care that follow a patient throughout their lifetime. Additionally, the technology can enhance care coordination, engagement, and clinician efficiency. In this ideal scenario, the patient shifts from being only the recipient of care to being the driver of care benefiting from a connected, well-orchestrated care planning model.
Cerner One Plan is a comprehensive, patient-centered solution that helps enhance connectivity and collaboration across different care venues within the enterprise and beyond. Learn more here.