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LCC Longitudinal Care Planning A Vision of the Longitudinal Coordination of Care Workgroup June 10, 2012
LCC
Longitudinal Care PlanningA Vision of the
Longitudinal Coordination of Care Workgroup
June 10, 2012
LCC2
LCC Workgroup Leads/Co-authors
•Larry Garber, MD LTPAC Care Transitions•Terry O’Malley, MD LTPAC Care Transitions•Bill Russell, MD Longitudinal Care Plan•Joanne Lynn, MD Longitudinal Care Plan•Laura Heermann Langford,PhD,RN Longitudinal Care Plan•Russ Leftwich, MD Longitudinal Care Plan•Susan E. Campbell, PhD, RN Longitudinal Care Plan•Jennie Harvell Pt. Assessment Summary•Sue Mitchell, RHIA Pt. Assessment Summary
LCC
Patients are evaluated with assessments (history, symptoms, physical exam, testing, etc…) to determine their status
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Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
LCC
Health Conditions/ Concerns
Risk Factors• Age, gender• Significant Past Medical/Surgical Hx• Family Hx, Race/Ethnicity, Genetics• Historical exposures/lifestyle (e.g.
alcohol, smoke, radiation, diet, exercise, workplace, sexual…)
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Dise
ase
Prog
ress
ion
Active Problems
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Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
Risks
Side effects
Patient Status helps define the patient’s current conditions, concerns, and risks for conditionsRisks/concerns come from many sources
Treatment
LCC
Health Conditions/ Concerns
Risk Factors• Age, gender• Significant Past Medical/Surgical Hx• Family Hx, Race/Ethnicity, Genetics• Historical exposures/lifestyle (e.g.
alcohol, smoke, radiation, diet, exercise, workplace, sexual…)
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Dise
ase
Prog
ress
ion
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)
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Prioritize
Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
Risks
Side effectsGoals for treatment of health conditions and prevention of concerns are created collaboratively with patient taking into account their statuses and Care Plan Decision Modifiers
Treatment
LCC
Health Conditions/ Concerns
Risk Factors• Age, gender• Significant Past Medical/Surgical Hx• Family Hx, Race/Ethnicity, Genetics• Historical exposures/lifestyle (e.g.
alcohol, smoke, radiation, diet, exercise, workplace, sexual…)
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Dise
ase
Prog
ress
ion
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)
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Prioritize
Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
Risks
Side effects
Decision making is enhanced with evidence based medicine, clinical practice guidelines, and other medical knowledge
DecisionSupport
Treatment
LCC
Health Conditions/ Concerns
Risk Factors• Age, gender• Significant Past Medical/Surgical Hx• Family Hx, Race/Ethnicity, Genetics• Historical exposures/lifestyle (e.g.
alcohol, smoke, radiation, diet, exercise, workplace, sexual…)
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Dise
ase
Prog
ress
ion
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
DecisionSupport
DecisionSupport
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Orders, etc..Prioritize
Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
Risks
Side effects
Interventions and actions to achieve goals are identified collaboratively with patient taking into account their values, situation, statuses, risks & benefits, etc…
Treatment
LCC
Health Conditions/ Concerns
Risk Factors• Age, gender• Significant Past Medical/Surgical Hx• Family Hx, Race/Ethnicity, Genetics• Historical exposures/lifestyle (e.g.
alcohol, smoke, radiation, diet, exercise, workplace, sexual…)
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Dise
ase
Prog
ress
ion
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
DecisionSupport
DecisionSupport
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Orders, etc..
CarePlan
Prioritize
Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
Risks
Side effectsThe Care Plan is comprised of Modifiers, Conditions/Concerns, their Goals, Interventions/Actions/Instructions, Assessments and the Care Team members that actualize it
LCC
Health Conditions/ Concerns
Risk Factors• Age, gender• Significant Past Medical/Surgical Hx• Family Hx, Race/Ethnicity, Genetics• Historical exposures/lifestyle (e.g.
alcohol, smoke, radiation, diet, exercise, workplace, sexual…)
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Dise
ase
Prog
ress
ion
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
DecisionSupport
DecisionSupport
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Orders, etc..
CarePlan
Prioritize
Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
OutcomesRisks
Side effects
Interventions and actions achieve outcomes that make progress towards goals, cause interventions to be modified, and change health conditions
LCC
Health Conditions/ Concerns
Risk Factors• Age, gender• Significant Past Medical/Surgical Hx• Family Hx, Race/Ethnicity, Genetics• Historical exposures/lifestyle (e.g.
alcohol, smoke, radiation, diet, exercise, workplace, sexual…)
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Dise
ase
Prog
ress
ion
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
DecisionSupport
DecisionSupport
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Orders, etc..
CarePlan
Prioritize
Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
OutcomesRisks
Side effects
The Care Plan (Concerns, Goals, Interventions , and Care Team), along with Risk Factors and Decision Modifiers, iteratively evolve over time
LCC
Health Conditions/ Concerns
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
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CarePlan
A many-to-many-to-many relationship exists between Health Conditions/Concerns, Goals and Interventions/Actions
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LCC
Health Conditions/ Concerns
Risks/Concerns:• Atherosclerosis• Hypoglycemia• Diarrhea• Myositis• Hepatitis
Diabetes MellitusHyperlipidemia
Goals• A1C < 7• LDL < 100• Exercise 3x per
week• Normal liver and
muscle tests
Interventions/Actions•Metformin• Atorvastatin•Walking• Testing blood sugars• Call MD if FSBS>300• Testing cholesterol• Testing liver enzymes• Testing muscle enzymes
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
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CarePlan
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Dise
ase
Prog
ress
ion
Side effects
Example:
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Health Conditions/ Concerns
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
CarePlan
Patient Status• Functional• Cognitive• Physical• Environmental
Care Team Members each have their own responsibilities
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LCC
Health Conditions/ Concerns
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
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CarePlan
Patient Status• Functional• Cognitive• Physical• Environmental
Patient Assessments and testing have many sources
Patient Family Physicians Non-physician Providers
Nursing Coordinators
LCC
Health Conditions/ Concerns
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
CarePlan
Patient Status• Functional• Cognitive• Physical• Environmental
Registries and Clinical Decision Support used by the Patient-Centered Medical Home identify when patient assessments, testing and/or interventions are overdue, or other deviations from the Care Plan exist
Registries and Clinical Decision Support in
Patient-Centered Medical Home
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LCC
Health Conditions/ Concerns
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
CarePlan
Patient Status• Functional• Cognitive• Physical• Environmental
Care Plan transporting, synchronizing and viewing
Patient Family Physicians Non-physician Providers
Nursing Coordinators
The Care Plan is filtered, translated and transported to meet the needs of each participant/setting in the patient’s care
LCC
Health Conditions/ Concerns
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
CarePlan
Patient Status• Functional• Cognitive• Physical• Environmental
How to represent many-to-many-to-many-to-many???
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LCC
Health Conditions/ Concerns
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
CarePlan
Patient Status• Functional• Cognitive• Physical• Environmental
The MAP Master All-care Plan
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Master All-care Plan• Item #1• Item #2• Relationship (e.g. Goal-for-Problem, Intervention-for-
Problem, Goal-for-Intervention, Performing Team Member-for-Intervention, Performing Team Member-for-Assessment, Team Member Responsible-for-Problem, Team Member Following-Problem, Problem-Problem Causality, etc…)
LCC
Health Conditions/ Concerns
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
CarePlan
Patient Status• Functional• Cognitive• Physical• Environmental
The MAP Master All-care Plan enables many views
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Master All-care Plan• Item #1• Item #2• Relationship (e.g. Goal-for-Problem, Intervention-for-
Problem, Goal-for-Intervention, Performing Team Member-for-Intervention, Performing Team Member-for-Assessment, Team Member Responsible-for-Problem, Team Member Following-Problem, Problem-Problem Causality, etc…)
Patient Physicians Nursing Coordinators
Which problems am I
responsible for?
Who on my Care Team is taking care of my wound?
What problems are treated by
this intervention and what are the
goals of treatment?
What interventions
are in place for this health concern?
Family Non-physician Providers
Patient Physicians Nursing Coordinators
LCC
Health Conditions/ Concerns
Risk Factors• Age, gender• Significant Past Medical/Surgical Hx• Family Hx, Race/Ethnicity, Genetics• Historical exposures/lifestyle (e.g.
alcohol, smoke, radiation, diet, exercise, workplace, sexual…)
Risks/Concerns:• Wellness• Barriers• Injury (e.g. falls)• Illness (e.g. ulcers,
cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…)
Dise
ase
Prog
ress
ion
Active Problems
Goals• Desired outcomes
and milestones• Readiness• Prognosis• Related Conditions• Related
Interventions• Progress
Interventions/Actions(e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…)• Start/stop date, interval• Authorizing/responsible
parties/roles/contact info• Setting of care• Instructions/parameters• Supplies/Vendors• Planned assessments• Expected outcomes• Related Conditions• Status of intervention
Care Plan Decision Modifiers• Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…)• Patient situation (access to care, support, resources, setting, transportation, etc…)• Patient allergies/intolerances
DecisionSupport
DecisionSupport
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Orders, etc..
CarePlan
Prioritize
Patient Status• Functional• Cognitive• Physical• Environmental
Assessments
OutcomesRisks
Side effects
Questions?
