1. Care Plans and Legos

2. Approach Start by asking the “receivers” of a plan of care “What do you need and want in the plan?” Define the “output” of a plan of care –What will it be used for? –What are the key components of the output? –What does it look like? Define the “inputs” necessary to create the “outputs” Leave the “process” of converting inputs to outputs for another day

3. Nested Plans of Care - Three Flavors Level 1: The “Core Plan of Care” –High level –Defined by the Patient and Advisor Level 2: The “Longitudinal Plan of Care” –Plan to inform care across all sites, all episodes –Requires a “Steward” to maintain and deploy Level 3: The “Local Plan of Care” –Site and/or issue specific plans (HHA, Burn Unit, etc) –Local implementation (site, practice, clinician) –Defined by Care Team and Clinician

4. Level 1: “The Core Plan” The “Big Picture” or “Master” Plan of Care (PoC) Plan Owner: Patient, Surrogate/Advisor Inputs: –Patient defined goals (Longevity, Function, Comfort) –Relative importance of goals –Prioritized list of Health Concerns –Limitations on interventions Outputs: –Prioritized list of health concerns matched to goals –List of any explicit limitations on interventions

5. Level 2: The “Longitudinal” PoC The “Multi-site” PoC Plan Owner: PoC “Manager” (Steward, PCP, CM, Navigator) whose role is to collaborate with the Patient to translate the Core Plan into a blueprint for action Inputs: –Prioritized list of Health Concerns matched to Goals –Prioritized Interventions matched to Goals –Team Members Accountable for Implementation matched to Health Concern(s) Output: –List of Accountable Providers matched to each Health Concern –Measurable outcomes for each Intervention

6. Level 3: The “Local” PoC The “Condition” or “Site Specific” PoC Plan Owners: Multiple. The local Team, Site and/or Accountable Providers Inputs: –List of Prioritized Interventions –List of Accountable Providers matched to each intervention –Measurable outcomes associated with each Intervention Outputs: –Assessment of success of each intervention –Recommendations for any changes to Core or Longitudinal PoCs based on response

7. Legos Needed for These Plans Health Concerns Patient Goals of Care Prioritized Goals of Care Cross-walk of Goals and Health Concerns Prioritized Health Concerns Prioritized Interventions Team Members Accountable Team Members Anticipated/Desired Outcomes by Intervention Changes in Goals, Concerns and Interventions

8. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care PoC Legos

9. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care Putting the PoC Legos Together Level 1: Core Level 2: Longitudinal Level 3: Local

10. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care The “Core” PoC Establish Index of Health Concerns

11. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care The “Core” PoC Establish Goals of Care

12. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Core” Plan of Care Prioritize Goals of Care “Core” Plan of Care

13. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Core” Plan of Care Filter Health Concerns by Prioritized Goals

14. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Core” Plan of Care Produce Crosswalk

15. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Core” Plan of Care Produce List of Prioritized Health Concerns

16. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Longitudinal” Plan of Care Develop Prioritized Interventions

17. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Longitudinal” Plan of Care Create list of Accountable Team Members

18. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Longitudinal” Plan of Care Assign outcomes to Responsible Team Member

19. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Longitudinal” Plan of Care Establish measurable outcomes

20. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Local Entity” Plan of Care Measure Progress towards desired outcomes

21. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care “Local Entity” Plan of Care Identify changes to Goals, Concerns

22. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care Repeat the Cycle Modify Health Concerns Modify Goals

23. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care Repeat the Cycle Modify Health Concerns Modify Goals of Care

24. Index of Health Concerns Changes: Goals Concerns and Interventions Prioritized Goals of Care Outcomes by Intervention Accountable Team Members Crosswalk Of Concerns And Goals Prioritized Health Concerns Prioritized Interventions Team Members Goals of Care