The Power of a Tech-Enabled Patient-Centered Care Plan

A recent patient experience validated the power of a current, comprehensive, and readily available patient-centered care plan.

Luiz and Mariana Lopez* recently had their one-month follow-up visit for their young son, Pedro, who is enrolled in the Pediatric Comprehensive Care Program at a Boston-area hospital. Their doctor is nationally recognized as an expert in caring for children with complex medical needs and through her experience has confirmed the importance of a team-based care approach and a comprehensive, patient-centered care plan. The care team has determined they need the care plan to have the following elements in order to effectively manage the care of the complex patients they serve:

• be a living document, with input from multiple authors;
• incorporate social and lifestyle needs;
• use patient-friendly language and reflect patient and family priorities.

Therefore, at the end of the follow-up visit, Pedro’s care plan was updated to reflect his current care strategies and the roles of each member of his team. Through a cloud-based platform, these updates were then readily accessible to all members of his care team – including providers in other healthcare organizations as well as school and community resources that all play a key role in his day-to-day care.

If we fast-forward just a few weekends, we can see the importance of maintaining an updated and readily accessible care plan. Mariana had taken Pedro with her to run her regular Saturday errands, and unfortunately while she and Pedro were at the mall, Pedro suddenly collapsed and experienced a series of seizures. Pedro was rushed to an Emergency Department, which was a new facility for the Lopez family, and the hospital had none of Pedro’s records.

Mariana told the ED staff that Pedro has several complicated medical and mental conditions, which are being managed by a team in Boston, and he has specific protocols that need to be followed in case of emergency. She was quickly able to show his care plan via her smartphone and grant access to the physician for his own viewing and editing via a shareable web link and PIN. The physician quickly read the emergency recommendations – noting that Pedro needs double his usual anti-seizure medication when his blood sugar is low – and then printed the plan to put in their own EMR.

Pedro’s father, Luiz, made his way to the hospital after being alerted by a text message from his wife. He also saw an automated email from the cloud-based care plan tool  noting that Pedro’s care plan had been securely accessed. He was reassured to know that the new clinical team had easy access to the plan of care and that Pedro was being properly cared for at the hospital.  

Serious negative implications were avoided because of the accessibility of the up-to-date care plan.  

The patient’s plan of care is the most important document in healthcare.

The scenario above demonstrates the criticality of coordination across care settings, empowering patients and their caregivers, and all care team members having access to the right information at the right time. The entire medical record with historical information was not needed; the clinical team needed to know synthesized critical information, such as medications, and the plan.

As a nation, we are taking steps to transform our healthcare system into one that truly puts patients at the center of every process. Healthcare organizations are recognizing this importance, yet also feeling the pain, as they transition to performance based contracts and new care delivery models such as Clinically Integrated Networks and PCMHs.

One of the requirements for PCMH recognition is to implement care planning processes for at least 75% of patients who may benefit from enhanced care management; providers have told us this is the most challenging part. Newly formed ACOs are driving the attempt to collaborate and payers are offering to reimburse providers to coordinate care (TCM & CCM reimbursement), yet it’s proving difficult to achieve in practice. While it would be ideal if EMRs could meet this need, unfortunately, they don’t. Patients often require care from multiple organizations (with different EMRs) as they move across the continuum of care and can’t always make sense of clinical documentation that is formatted for billing. It is very difficult to realize and share the critical elements and action items associated with a care plan, which should be understood by a patient, and also edited by the rest of the team surrounding the patient. As a pediatric care coordinator in one of our programs told us, “Previously, I had no tools to work across all the players supporting the family and child.” Care teams need a way to efficiently develop and share a care plan, including the patient and family, and jointly execute upon the associated care activities.

This is about Pedro’s plan, and the job to be done is to purposefully get his plan into the right hands at the right time so that he gets the right care.

Key Components of Patient-Centered Care Plans:

In the 2014 PCMH Standards and Guidelines, the National Committee for Quality Assurance outlines the following checklist of components to be incorporated into care planning processes:

• Patient preferences and functional/lifestyle goals
• Treatment goals
• Assessment of potential barriers to meeting goals
• Strategies for addressing potential barriers to meeting goals
• Care team members, including family, friends and caregivers; primary care provider and support staff; care manager; specialists; behavioral health providers; pharmacists; and community resources.
• Medical summary with current problems, medications, allergies, etc.
• Emergency crisis plan
• Self-care plan with monitoring steps and education resources for patients/caregivers

These plans ensure everyone involved in the care of a patient is on the same page as patients move through care and empower and build trust with patients and their caregivers. The sum of these components should be greater than the parts.

The path to the achieving the Triple Aim

Is the path to achieving the Triple Aim really as simple as putting patients at the center and enabling providers to work together? Earlier this year, Atul Gawande told Quartz that the most profound improvements in care delivery begin with “asking some very simple, very basic questions that we never ask.” Gawande is building on the work of Clayton Christensen at Harvard Business School. Christensen developed the theory of disruptive innovation, describing innovations that transform existing markets by introducing simplicity, convenience, accessibility, and affordability where high-cost and complication are the status quo. We need to look at the challenges of team-based care differently, and a great place to start is by pushing solutions that power dynamic, patient-centered care plans. All team members need to be able to access, update, and share how we’re working to achieve the desired outcomes. It’s that simple, and it’s that hard.

(Disclosure: Clay Christensen is on my Board of Directors.)

*Names have been changed to protect the family’s privacy.

Photo Credit: Amanda Mills, CDC