Care Plan, Plan of Care and Treatment Plan Storyboard: workflow scenarios and use of the three types of plans LCC Perspective: The only difference between the three plans is the level of complexity A treatment plan is for one health concern/problem. If there are multiple health concerns, there are multiple treatment plans. When a patient has multiple health concerns or plans from multiple specialists (treatment plans) and there are conflicts between the plans that need to be resolved a Plan of Care is created. With all this said, it is ok to have a Care Plan for only one health concern Scenarios and Actors Treatment Plan Plan of Care Care Plan A 42 yo female patient is newly diagnosed by his PCP (primary care provider)/GP (general practitioner) to have rheumatoid arthritis PCP/GP initiates a treatment plan that includes: Health concern/problem: rheumatoid arthritis slightly overweight Health goals: effective pain control prevent acute exacerbation effective weight control self-care participation … Interventions: Meds: e.g. NSAIDS, corticosteroid, Ca++, VitD Rest, proper positioning of joints … Follow-up appointment in 4 weeks to discuss longer term plan of care PCP/GP discusses health concerns/problem, goals and interventions with patient Patient agrees to treatment plan Treatment plan agreed to by patient and implementation of plan actions (interventions) starts LCC Perspective:There will be 2 treatment plans as the patient has 2 health concerns) Each health concern has a treatment plan. Start the patient journey with one health concern (overweight) nil LCC Perspective: 1 Plan of Care - Clinician reconciles conflicts of Treatment Plans into a Plan of Care Nil Patient returns to PCP/GP clinic after 4 weeks Patient is assessed for: Health status Progress of health problem The PCP/GP reviews the previous treatment plan and updates the plan according to new assessment findings Updated treatment plan LCC Perspective: Updated treatment plans LCC Perspective: Updated Plan of Care nil
Patient is also assessed for Longer term management needs including Needs for other professional care services Rheumatologist Physiotherapist Occupational therapist Dietitian Pharmacist Clinical psychologist Social worker, etc The PCP/GP develops a plan of care for management of the patient’s complex health concerns/problems arising from the rheumatoid arthritis Referral to other health care providers The patient agrees with the longer term plan of care and referrals to other health care professional as recommended by PCP/GP Plan of care for managementof complex health problems LCC Perspective: Plan of Care is created when 2 or more treatment plans need to be reconciled) + referrals The patient makes appointment with and is seen by the following health care professionals / specialist for assessment and care: Rheumatologist Physiotherapist Occupational therapist Dietitian Pharmacist Clinical psychologist Social worker, etc Each health care professional/specialist identifies one or more health concern/problem from his/her perspective, discusses discipline specific treatment plan with the patient The treatment plans are accepted by the patient (some with modifications) Each health care professional/specialist produces a progress report that includes relevant components of treatment plan to be sent to patient’s PCP/GP Discipline specific treatment plans LCC Perspective: or Plans of Care (depending on # of health concerns per specialist) Progress notes (with treatment plan components) to PCP/GP Discipline specific plan of care Progress notes with treatment and plan of care nil LCC Perspective: Care Plan is