Care Plans 2017

Pressures to improve care at lower cost. Higher healthcare costs are creating pressures on those who pay – government, employers, insurers and individuals. Most recent efforts have not reduced and sometimes have increased costs, and treatment advances have added more costs for cancer and other serious diseases. What strategies are left to improve care for patients while reducing overall expenditures? Ways to better coordinate and communicate are being investigated, one of which is using multi-disciplinary, interactive and longitudinal Care Plans for patients to co-create and use outside institutional settings.

Patient-centered Care Plans. Making a Care Plan patient-centered starts with involving the patient, often with one or more family members, when addressing a health issue. It might be a newly-diagnosed disease, such as heart failure, or a health goal, such as losing weight to reduce cardiovascular risks. The place to start is to help the patient understand the problem to be addressed, including what is causing the problem and why it is a problem. That involves sharing educational materials, often in a sequenced way to avoid overwhelming the patient, and continuing to create and fine-tune the Care Plan. The next step is to identify and agree on goals to be reached, accompanied by identifying steps to reach those goals.

For example, a patient hearing a diagnosis of Type 2 Diabetes will need to understand why the disease is a problem, and what will be most effective in impacting that problem. By understanding what risks and complications are associated with Type 2 Diabetes, the decision about where to start becomes easier. Blood pressure control may be the most pressing issue. If so, strategies to monitor and control blood pressure will be discussed. If blood glucose control is the most important issue, strategies to monitor and control blood glucose levels will be emphasized.

A patient with Type 2 Diabetes will usually receive information from many sources. Their doctor will start by recommending education from a Diabetes Education Center (DEC). The DEC provides classes and on-going education and support for all stages of the disease, and they coordinate with the patient’s doctor by fax or mail today. But what if specialists get involved? What happens when the patient is hospitalized? What happens if the patient has an urgent medical need when travelling? There are not good systems in place today, and communication can easily get missed with real consequences to the patient and add avoidable expenses.

Having a patient-centered Care Plan available to the patient, family caregivers and clinicians helps solve the communication and coordination problem. If the patient needs their gall bladder removed, their Type 2 Diabetes Care Plan is available to clinicians involved so medication and nutrition plans can be incorporated into their hospital Care Plan. If issues are identified in the hospital, such as uncontrolled blood pressure or blood glucose, or new complications arise, such as foot numbness suggesting peripheral neuropathy, clinicians working to manage the Type 2 Diabetes can be made aware and address it when the patient has returned home. Because the patient and caregivers are focusing on their health and recovery, this is a good time for the patient review their goals to see if they have changed, or if the plan to reach the goals should be adjusted.

Sharing Care Plans for better coordination. One of the biggest issues when clinicians from different organizations work with the same patient is knowing what each other is doing. In our example, if the doctor, DEC clinicians, pharmacist and hospital discharge nurse give different education and instruction materials to the patient, how does the patient and family know what to do? Having a place where current education materials, goals and the plan to reach those goals can be accessed and, when necessary, adjusted by the clinicians involved would solve many of the ongoing problems associated with care coordination.

In our example, the patient would attend diabetes education classes at the DEC and receive information about blood glucose testing and possibly recommendations for medication adjustment. The referring physician will receive a report from the DEC, but getting the information to everyone who needs it is difficult, and communicating on an ongoing basis is even more so. To address this, some have proposed that a digital Care Plan that can be created, then sent from place to place, updated by whoever needs to do so, is the way to go. When a new version of the digital Care Plan shows up, the old one is automatically updated. Others have suggested that different sections of the Care Plan be owned by different providers. “Type 2 Diabetes” Care Plan is at one doctor’s office or DEC, and “Heart Failure” Care Plan is at another doctor’s office. When the patient visits another provider setting, all the sections can be brought together in one place so that a new provider, such as an urgent care center, and see the aggregated Care Plan. Both of these proposals are problematic because (1) it’s unlikely that either will result in an accurate and up-to-date version at every site of care; and (2) the patient or caregiver isn’t at the center of the changes to interact with those changing the Care Plan and to make sure the Care Plan is realistic and being followed. This may be why many coordinators still rely on a “3 ring binder” or a paper file system to carry around information to various providers and update on with new paper versions as Care Plans and educational resources require changes.

Alternatively, when developing the Datuit Care Plan Manager (CPM), the issues of trying to bring data together in one place are addressed by putting the patient in the middle for a couple of reasons. First, finding a complete medication list can be difficult, and a complete medication list is necessary for safe care to be delivered in any setting. Second, Care Plan sections in different organizations can potentially have conflicting recommendations, confusing patients and clinicians alike. Even when attempting to reconcile differences, in many instances they won’t get resolved. Patients and family members will be left scratching their heads or trying to resolve the issues themselves (if they can even recognize the conflict). Third, care can only be coordinated when team members can identify who else is involved. Datuit’s CPM brings a team of clinicians and caregivers, along with the patient, into an environment where a Care Plan can be created, viewed, adjusted, shared by everyone has the rights to do so. Secure messaging is included, as well as exchanging information with electronic health records (EHRs) via Direct messaging or by API. Additional tools, such as digital health devices, can also be plugged into the CPM so the information will display in the CPM. In this way, a patient’s care team members can literally be “on the same page” when evaluating the Care Plan for adequacy and effectiveness. Also, when necessary, a message can be sent to one or more care team members (including the patient and caregivers) to resolve an issue.

Paying for value in healthcare. Government and private payers have been looking for ways to reduce costs while still promoting quality outcomes. In recent efforts to bake more coordination into care delivery, costs have often exceeded benefits. In the new payment models, provider organizations are asked to assume more “risk” – receive a set payment for a “bundle” of care or a defined period of time. That means that they could lose money if patients use more high cost care – usually emergency care and hospitalizations. Providers and clinicians ask if they use this approach and it means more work, will they be adequately compensated for the time and effort? Will patients and caregivers take up more time than they have available in today’s time-constrained environment, and will patients and caregivers be able to participate in the anticipated manner? Innovation is just beginning to occur to reduce high cost, unnecessary care, and “team care” and technology are almost always in the mix. Datuit’s CPM supports a dynamic approach to collaborative team care by enabling real-time information sharing and asynchronous communication among all care team members.

As healthcare organizations – those who provide care and those who provide products and services to provider organizations – begin to adapt to the “pay for value” paradigm, they will adjust the way they value what they do and measure their effectiveness. In today’s world, care is often complicated and involving several providers, clinicians, services, products (including but not limited to medications) and even payers. Patients are picking up more of the tab themselves so are beginning to look for the most economical solutions. Although it involves work to do it effectively, coordination saves time and money. Getting it right will take time, and it may even look different for different conditions and age groups. The good news is it’s beginning to happen all over the world, and with increasing momentum, healthcare is coming into the 21st century.