The Accountable Patient Blog: The Future of Personal Care Plans

Don Kemper, MPH, Founder (Retired)

There shall be wings! If the accomplishment be not for me, ’tis for some other.—Leonardo da Vinci

March 1st is International Future Day and nowhere is the future rushing toward us faster than in health care.

The move away from paying a fee for every service to paying hospitals and doctors to keep us healthy is shifting medical workflows, priorities, and cultures faster than we could have imagined. This dawning era of accountable care is bringing new focus to patient accountability as well.

One aspect of health care ready to jump into the future is that of the personal care plan. Most doctors, nurses, and hospitals work with care plans for most patients—but no two are quite alike. They are rarely shared across the full care team and even more rarely shared with the patient. Over the next few years, all that will change dramatically.

Care Plans 2.0 is an aspirational look into the future of care plans. The vision was created by a coalition of forward-thinking consumer champions as part of the Consumer Partnership for eHealth. Healthwise is a participating member of the Partnership.

The Care Plans 2.0 vision calls out five Care Plan Principles paraphrased as follows:

  1. Care plans should be focused on the patient’s goals that evolve with the changing needs of the patient.
  2. They should allow care team members, including the patient, to access and add to the care plan.
  3. They should identify barriers to the patient’s success in achieving the desired goals.
  4. They should specify accountabilities for both the patient and provider appropriate to each’s abilities.
  5. They should benefit and be made available for every person, without exception.

Care Plan 2.0 provides a good start for envisioning a future with more coordinated care. Each person’s plan would evolve from a wellness base, through the management of chronic conditions, and all the way to care and support near the end of life. At every stage, the care plan should identify the individual’s most meaningful goals at that time and then create a path to support achievement of the goal.

  • For the young and healthy, the goals may well focus on wellness and the ability to get full enjoyment out of life while avoiding risks that could later threaten one’s health.
  • For the chronically ill, the care plan may be set on assuring that every care team member is part of a coordinated team with a common treatment goal aligned with the goals of the patient.
  • And for those who are frail and at high risk, the care plan should help assure that the care they receive is well-matched to their personal preferences.

While today it may seem that we remain a long way off from the aspirational care plans described above, the future is coming toward us at a remarkable pace. With a big push from the Partnership, from the Meaningful Use 3 rules, and from the triple-aim demands of accountable care, the future will be here much faster than you might think. Why not be ready to catch it?