1. Behavioral Health Integration Complex Care Initiative
SHARED CARE PLANNING
Stacey Devenney, MA, CDP
Kitsap Mental Health Services
Marc Avery, MD, Psychiatrist
University of Washington School of Medicine

2. Why use a Shared Care Plan?
Primary Reasons:
Assure that providers are incorporating patient values and care preferences.
Assure that providers consistently address key health/treatment goals as defined by the patient.
Secondary Reasons:
Facilitate ongoing engagement in care.
Improve patient self-management.
Facilitate Coordination of Care

3. The Art of “Sharing:
NOT just a compilation of each provider’s care plan.
Is often different thant WHAT primary care clinicians are used to – it is different than many “CHECK:IST” style EMR “care plans”
SHOULD be incorporated into CARE MANAGER’s routine appointments (NOT something that is just done once every 3 months!!!
The “Shared” part of Shared Care Planning means that the over-arching wellness goals are shared between providers and caregivers where appropriate.
Few EMR platforms contain the full functionality for this – especially for sharing between different providers.
Providers therefore need to develop tools or workflows
for achieving this goal, e.g:
Patient “wallet cards”
(example to follow)
Registries
Plain old paper/fax

4. What is a Shared Care Plan?
An over-arching set of patient-expressed health goals, values and preferences.
Strengths:
What are the patient’s strengths that will help him/her reach their health goals
Barriers:
What might get in the way of them being where they want to be
Action Steps: - This is the part that might be new or different for some of you. This is not goal or objectives as you know them. These are 2-3 things that
the Client/Patient will do
You – the Clinician will do
Measures - These may come in 2 foms
Standard Measures – ie PHQ9
Patient Centered Measures – crying less
Care Team – anyone who has Action Steps
Family, Patient, Pastor, Clinician other Natural Supports

5. Developed collaboratively with the patient/client
What makes an Effective Shared Care Plan?
Developed collaboratively
Written in “plain language”
Incorporated into routines
Identifies specific actions
Indicates who is involved
Developed collaboratively with the patient/client
Written in “plain language”
in patient’s own words where possible.
literacy level sensitive
Is incorporated into routine workflows
Huddles and Systematic Caseload Reviews.
Care Management Appointments.
Is updated frequently
Identifies specific steps or actions to be carried out by patient and healthcare team
Indicates who is involved in the patient’s care/care team--including specialty providers, and family or other natural supports.

6. Example
Example of CCC: Meant to be something patient can take home AND be filed in the chart.
Would be modified by providers

7. Example, part 2
As you can see this care plan incorporates the items that Stacey has already mentioned.

8. Example folding SCP from Tuolumne County
NOT just a compilation of each provider’s care plan.
Is often different thant WHAT primary care clinicians are used to – it is different than many “CHECK:IST” style EMR “care plans”
SHOULD be incorporated into CARE MANAGER’s routine appointments (NOT something that is just done once every 3 months!!!

9. Practice with Partner Exercise, (5 minutes X 2)
Partner A:Pretend you are the patient. You can use yourself or the vignette provided.
Partner B: Pretend you are the care manager
Practice eliciting from partner A at least:
One Goal statement
One strength and one barrier
One Action Step
Decide how progress/success will be measured
How do you feel this will work for you.
Switch Sides – and repeat!
SEEMS BEST WAY TO ELLICIT PRACTICE IS TO GIVE CASES AND SEE HOW THEY WOULD GET GOAL OUT OF THE CLIENT??
INTERACTIVE DISCUSSION:
Patient’s Care Goals (chronic and preventive)
Patient’s Self Management Tools:
Patient’s barriers to care:
Team Goals

10. Report Out
How might you incorporate this approach into your daily practice? How do you envision this working in your clinic?