1. Care Plan Christopher Lamer, PharmD, MHS, BCPS, CDE CDR U.S. Public Health Service

2. Dis-C.Lamer I dont know anything about care plans

3. Meaningful Use Final Rules August 2012 Stage 2 EHR Certification Testing May 2013 Stage 2 CEHRT deployment Oct 2013 –SNOMED Oct 2013 –ICD-10 Oct 2013 Last quarter to demonstrate stage 2 MU –July to September 30 2014

4. Stage 2 MU SNOMED – problem list, POV, Fam Hx Consolidated Document Architecture (CDA) EMAR/BCMA for hospitals Auditing Personal Health Record (PHR) Secure Messaging Cancer Registry Management

5. Common MU Data Set 1. Patient name 2. Sex 3. Date of birth 4. Race 5. Ethnicity 6. Preferred language 7. Smoking status 8. Problems 9. Medications 10. Medication allergies 11. Laboratory test(s) 12. Laboratory value(s)/ result(s) 13. Vital signs (height, weight, BP, BMI) 14. Care plan field(s), including goals and instructions 15. Procedures 16. Care team members

6. What is a care plan?

7. A plan for the medical care of a particular patient or the welfare of a child in care A plan, based on a nursing assessment and…diagnosis…The nursing care plan is begun when the patient is admitted to the health service…The goal of the process is to ensure that nursing care is consistent with the patient's needs and progress toward self-care. A written nursing care plan should be a part of every patient's chart. Strategies designed to guide health care professionals involved with patient care. Such plans are patient specific and are meant to address the total status of the patient. Care plans are intended to ensure optimal outcomes for patients during the course of their care. A document developed after the patient assessment that identifies the nursing diagnoses to be addressed in the hospital or clinic. The plan of care includes the objectives, nursing interventions, and time frame for accomplishment and evaluation. It should be formulated with input from the patient and the patient's family. A care plan is a written statement of your individual assessed needs identified during a Community Care Assessment. It sets out what support you should get, why, when, and details of who is meant to provide it. You are entitled to be given a copy of your care plan.

8. Plan for continuity of medical care Focus on patients needs Focus on patients goals Focus on patients targets Total status of the patient Promotion of self-care Input from patient and family Collaboration & cooperation Medical Nursing Pharmacy Home health CHN Community Patient Family Shared responsibilities Community care assessment Outlines next steps Who is doing what Accessible to everyone Standards Electronic exchange

9. Plan for continuity of medical care Focus on patients needs Focus on patients goals Focus on patients targets Total status of the patient Promotion of self-care Input from patient and family Collaboration & cooperation Medical Nursing Pharmacy Home health CHN Community Patient Family Shared responsibilities Community care assessment Outlines next steps Who is doing what Accessible to everyone Standards Electronic exchange

11. CMS Definition of a Care Plan We propose to describe a care plan as the structure used to define the management actions for the various conditions, problems, or issues. For purposes of meaningful use measurement we propose that a care plan must include at a minimum the following components: –Problem (the focus of the care plan) –Goal (the target outcome) –Any instructions that the provider has given to the patient A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).

12. Standards What data fields are used (ICD10, SNOMED, LOINC, RxNorm, etc) Certification What EHRs need to be able to do Meaningful Use How EHRs need to be used CMSONCS&IHL7NIST

13. Standards and Interoperability A longitudinal care plan is needed in the health care delivery system to allow for continuous interactions between the care team and the patient using data exchange and to support the goal of a virtual care team approach to chronic disease management and long term/post acute care.

14. S&I: Problems Patient deficits are identified in several ways. For example, medical problems are one type of deficit and are based on Medical Diagnoses. Nursing diagnoses are another source of information for identifying patient problems. HL7 uses the concept of Health Concern to more completely express the range of deficits patients may experience. Health Concerns are identified through a number of processes.

15. S&I: Goals Segmentation of Goals by patient preferences and desired outcomes. –Goals may effect a number of outcomes achieved by interventions on multiple Health Concerns. –The relationship of the outcomes from interventions and the cumulative effect of multiple interventions on the achievement of patient goals is thought to be an essential functional requirement.

16. Health Conditions Risks/Concerns Injury (falls) Illness (ulcers, cancer, stroke, hypoglycemia) Risks/Concerns Injury (falls) Illness (ulcers, cancer, stroke, hypoglycemia) Risk Factors Age, gender Sig past Medical/Surgical History Family History, Race/Ethnicity, Genetics Exposures/lifestyle (alcohol, smoke, radiation, diet, exercise, workplace) Environment/Home Safety Test Result/Examination Findings Risk Factors Age, gender Sig past Medical/Surgical History Family History, Race/Ethnicity, Genetics Exposures/lifestyle (alcohol, smoke, radiation, diet, exercise, workplace) Environment/Home Safety Test Result/Examination Findings Goals Desired Outcomes Barriers Progress Related Conditions Related Interventions Goals Desired Outcomes Barriers Progress Related Conditions Related Interventions Interventions/Actions Medications, wound care, exercise, diet, tests, behavior changes, support, calling MD for symptoms, consults, rehab… Start/stop dates Frequency Responsible parties Setting of care Instructions/parameters Supplies Status of intervention Related conditions Interventions/Actions Medications, wound care, exercise, diet, tests, behavior changes, support, calling MD for symptoms, consults, rehab… Start/stop dates Frequency Responsible parties Setting of care Instructions/parameters Supplies Status of intervention Related conditions Acute Problems Chronic Problems Acute Problems Chronic Problems Disease progression Decision Modifiers Patient values/priorities/wishes/adv directives/readiness/expectations Patient status (functional, cognitive, symptoms, prognosis) Patient access to care/support/resources/transportation Patient allergies/intolerances Decision Modifiers Patient values/priorities/wishes/adv directives/readiness/expectations Patient status (functional, cognitive, symptoms, prognosis) Patient access to care/support/resources/transportation Patient allergies/intolerances Outcomes

17. What will our Care Plan look like?

18. Health Conditions Risks/Concerns Injury (falls) Illness (ulcers, cancer, stroke, hypoglycemia) Risks/Concerns Injury (falls) Illness (ulcers, cancer, stroke, hypoglycemia) Risk Factors Age, gender Sig past Medical/Surgical History Family History, Race/Ethnicity, Genetics Exposures/lifestyle (alcohol, smoke, radiation, diet, exercise, workplace) Environment/Home Safety Test Result/Examination Findings Risk Factors Age, gender Sig past Medical/Surgical History Family History, Race/Ethnicity, Genetics Exposures/lifestyle (alcohol, smoke, radiation, diet, exercise, workplace) Environment/Home Safety Test Result/Examination Findings Goals Desired Outcomes Barriers Progress Related Conditions Related Interventions Goals Desired Outcomes Barriers Progress Related Conditions Related Interventions Interventions/Actions Medications, wound care, exercise, diet, tests, behavior changes, support, calling MD for symptoms, consults, rehab… Start/stop dates Frequency Responsible parties Setting of care Instructions/parameters Supplies Status of intervention Related conditions Interventions/Actions Medications, wound care, exercise, diet, tests, behavior changes, support, calling MD for symptoms, consults, rehab… Start/stop dates Frequency Responsible parties Setting of care Instructions/parameters Supplies Status of intervention Related conditions Acute Problems Chronic Problems Acute Problems Chronic Problems Disease progression Decision Modifiers Patient values/priorities/wishes/adv directives/readiness/expectations Patient status (functional, cognitive, symptoms, prognosis) Patient access to care/support/resources/transportation Patient allergies/intolerances Decision Modifiers Patient values/priorities/wishes/adv directives/readiness/expectations Patient status (functional, cognitive, symptoms, prognosis) Patient access to care/support/resources/transportation Patient allergies/intolerances Outcomes

19. Plan for continuity of medical care Focus on patients needs Focus on patients goals Focus on patients targets Total status of the patient Promotion of self-care Input from patient and family Collaboration & cooperation Medical Nursing Pharmacy Home health CHN Community Patient Family Shared responsibilities Community care assessment Outlines next steps Who is doing what Accessible to everyone Standards Electronic exchange

20. Thank you! Christopher Lamer Office of Information Technology Chris.Lamer@ihs.gov (615) 669-2747