2/14/2017
Leslie Kelly Hall
My Latin teacher often said to me concerning my plans to do homework, “The best-laid plans of mice and men may still go awry.”
Care plans, plans of care, and collaborative care platforms all have things in common: helping people coproduce health. They represent shared decisions designed to serve all parties. The best plans evolve as new information, decisions, and impacts are identified. But, as my Latin teacher would understand, it’s not so easy to do in healthcare. Today most care plans are unilateral, given to a patient with the expectation that things will be done, without any way of knowing if things actually were done.
The complexity of healthcare, communication voids, and lack of coordination all contribute to make care planning difficult. So much of the success of a care plan is due to actions that a patient takes. The provider needs to know when and if actions have been taken, that the patient understands their plan, contributes to the plan, and is on track to meet the goals of care in that plan.
By mapping health education to every step of the care plan—including identifying where shared decision making tools can help guide the next step—we can make care plans more effective tools. A group of payers, providers, EMR vendors, and Healthwise worked together to demonstrate how effective care plans can be when technology and standards are aligned. This model can be shared and recreated across all stakeholder systems.
Using shared decision making to capture a person’s preferences and values and get that information back into the record brings the encounter full circle. The provider is better informed, and the patient is equipped to fulfill the care plan, leading to better health decisions. Together, we can make sure that the best laid plans come off without a hitch.